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Immigrants (NHS Treatment)

Volume 560: debated on Monday 25 March 2013

(Urgent Question): To ask the Secretary of State for Health what moves the Government intend to take to prevent the national health service becoming an international health service.

The current system of policing and enforcing the entitlement of foreign nationals to free NHS care is chaotic and often out of control. At a time when we are having to face the challenges of an ageing society, it places a significant and unjustified burden on our GP surgeries and hospitals and may well impact on the standard of care received by British citizens.

As the Prime Minister said earlier today, the Government are determined to ensure that anyone not entitled to receive free NHS services should be properly identified and charged for the use of those services. Currently, we identify less than half of those who should be paying and collect payment from less than half those we identify.

We also have some of the most generous rules in the world on access to free health care. Our rules allow free access to primary care for any visitor to the UK, including tourists, and free access to all NHS care for foreign students and temporary visitors. But ours is a national, not an international, health service, so last year, under my predecessor, we began a wholesale review of the rules and procedures on charging visitors for NHS care, with a view to making the regime simpler, fairer and easier to implement. In particular, we focused on who should be charged and how the rules can be applied and enforced more effectively. We have examined the qualifying residency criteria for free treatment; the full range of other current criteria that exempt particular services or visitors from charges for their treatment; whether visitors should be charged for GP services and other NHS services outside hospitals; establishing a more effective and efficient process across the NHS to screen for eligibility and to make and recover charges; and whether to introduce a requirement for health insurance tied to visas.

The initial phase of the review has concluded and we will shortly start a consultation on a range of options, including plans to extend charging to some visitors and temporary residents who were previously exempt so that the default qualification for free NHS care would be permanent, not temporary, residence; ending free access to primary care for all visitors and tourists; introducing a prepayment or insurance requirement for temporary visitors to pay for NHS health care; and improving how the NHS can identify, charge and recover charges where they should apply. We will retain exemptions for emergency treatment and public health issues.

We will work closely with medical professionals, NHS staff and partner NHS organisations during the consultation and then seek to introduce agreed changes as quickly as possible. We will need to take a staged approach, because some changes are likely to require primary legislation before they can be introduced, which will take longer to put in place. However, some changes can be made immediately, and we should proceed with those as quickly as possible.

I thank the Health Secretary for his reply. If he wants us to take him seriously, will he today give a commitment in respect of the directive his Department issued just as the House was rising for the summer recess, compelling doctors, if they have vacancies, to admit all those who have been in the country for 24 hours or more, including illegal immigrants? Will he ensure that someone in the NHS—not doctors—works out whether or not a person is entitled to claim, and will he implement such proposals forthwith?

The directive to which the right hon. Gentleman refers was issued by an independent NHS body, not my Department. The sorry truth is that it is consistent with the current rules on access to primary health care, which is what we believe is wrong. I think that one of the big problems in the current system is that we have free access to primary care for anyone visiting the UK, however short their visit is. Through that access to primary care, they get an NHS number, which should not entitle them to free care but is often treated by hospitals as such. That is what we have to put right. He is absolutely right that we need a system that properly identifies whether people should have care that is free at the point of access without impinging on the ease of access for British citizens, which is one of the things they treasure most about the NHS.

Does my right hon. Friend agree that it is through access to primary care that the initial control must take place, but that all hospitals should have an overseas visitors manager who should be designated and required to collect overseas visitors’ moneys on a more regular basis and using a more joined-up and coherent way of working with the other agencies involved?

What my right hon. Friend says bears very careful consideration. He is absolutely right that primary care is a critical access point, and we need to look at that. We also need to look at the burdens we place on GPs. I think that ultimately the easy way we will do that is through proper digital patient records, which will allow NHS professionals to find out about the medical history of people accessing the NHS at any point, including whether they are likely to be eligible for free treatment.

With regard to hospitals, my right hon. Friend makes a very interesting point about an overseas visitors manager. One of the problems we have is that the incentives in the system positively disincentivise hospitals from declaring foreign users of the NHS. If they declare someone not to be entitled to free NHS care, they have to collect the money from that person themselves, whereas if they do not declare the person not to be entitled to free NHS care, they get paid automatically by their primary care trust or clinical commissioning group. The incentives in the system have acted to suggest that this is a much smaller problem than I believe it is.

The NHS must not be open to abuse. Where people do not have entitlement to free treatment, steps should always be taken to recover the costs from individuals and Governments. That clear principle is shared by Members across this House.

For some time, hospitals have rightly had a legal duty to recover any charges owed from overseas patients. The previous Government proposed a number of further steps, including amending immigration rules so that anyone with substantial medical debts is not allowed back into the country. We welcome efforts to build on that, while always guarding against overblown rhetoric, which does not help the immigration debate. We therefore need more precision and clarity from the Secretary of State. First, on the scale of the problem, as ever with this Government’s announcements, there is already confusion to clear up. Earlier today, the Prime Minister’s spokesperson put the cost to the NHS of health tourism at £10 million to £20 million. On “World at One” this lunchtime, the Secretary of State said that he thinks it is more like £200 million. So which is it? Will the Secretary of State publish the evidence he has to support his claim?

Secondly, we need more detail on what the Government are proposing. Has the Secretary of State consulted those in Scotland, Wales and Northern Ireland on any proposed changes? There are practical questions on which health professionals will need reassurance. We have heard in the news today about the problems in the UK Border Agency. What assurances can the Secretary of State give to health professionals that they will not be used to plug the gaps that have been created by the Government’s severe cuts to the front line of the UK Border Force? Will they be given a simple way of checking eligibility and not be burdened by extra bureaucracy? Will these changes apply equally to planned and emergency care? If so, that could put health professionals in a difficult ethical position. Does the Secretary of State agree that care should always be provided in life-threatening situations, and will he take this opportunity to reassure health professionals on that important point?

Finally, the Secretary of State told “World at One” that one of the main reasons he was doing this was to relieve pressure on accident and emergency departments, particularly in London. While we commend moves to prevent abuse of the system, could he not better achieve his aim if he was not planning to close so many A and Es in London?

The Government have made a lot of assertions, but there is a real lack of policy clarity and evidence. Unless the Secretary of State can provide convincing answers to my questions, the House will be left with the distinct whiff of a cooked-up a story to suit the Government’s political purposes rather than a real drive to protect the NHS from abuse.

The Government are not going to take any lessons in overblown rhetoric when Labour Members talked about this problem for 13 years and did absolutely nothing about it. What was missing from the right hon. Gentleman’s remarks was a proper apology for Labour’s total failure to control our borders during a period in office that saw a quadrupling of net migration. We do not know how many people are residing in this country illegally, but in January the London School of Economics published a report stating that it could be nearly 900,000 people, in which case the cost will not be a few millions but many, many times that. In 13 years, Labour did not change eligibility for access to free NHS services and did nothing to improve the collection of proper dues from people coming from outside the European Union.

The £20 million figure that the Prime Minister’s spokesman used this morning is the amount of uncollected debt that is owed to the NHS by foreign nationals. If the right hon. Gentleman had listened to my response, he would know that we believe—of course it is impossible to get exact figures on this because of the total mess that the previous Government created—that we identify less than half the people who should be paying for NHS care and collect less than half the money that should be collected.

Of course we will work with very closely with Scotland, Wales and Northern Ireland to ensure a co-ordinated approach. If the right hon. Gentleman had listened to what I said, he would have heard that the exemption for emergency care and for public health issues will remain in place, which is extremely important.

Let me finish by talking about A and E issues. The reality is that the LSE estimates that about 70% of those living illegally in the UK live in London, where A and Es happen to face some of the biggest pressures. University College London Hospitals NHS Foundation Trust opened a new A and E only in the past few years and it was built for a capacity of 65,000 people a year, but it is now seeing 120,000 a year. If the right hon. Gentleman’s Government had done something about this rather than talk about it, A and Es across London would not be facing the pressure they are now facing.

Will the Secretary of State publish the names of those trusts that are abjectly failing to identify and recover charges from those who are not entitled to free care?

My hon. Friend makes a reasonable point. Part of the problem is that when we should be identifying someone as a foreign national who should pay for their NHS care, that does not happen a lot of the time because of the incentives in the system. Under the NHS improvement initiative, which is taking place in London at present—it is worth looking at that closely, because it has a lot of promise—there is a centralised collection of debt from foreign nationals who owe the NHS so that that does not become the responsibility of individual hospitals, which is something that is putting them off registering people as eligible for their NHS care.

May I invite the Secretary of State to comment on the view that one of the reasons why these proposals are being made at this stage is the conclusion of transitional arrangements for Romanians and Bulgarians at the end of this year? The Minister for Immigration is sitting on his right. Is it possible for the Health Department and the Home Office jointly to commission research so that we can have some actual figures on how many people might be coming at the end of this year?

The right hon. Gentleman will have to raise the matter of the actual number of people coming to the UK with the Home Secretary or, indeed, the Minister for Immigration.

The right hon. Gentleman is right to say that the issues that we are dealing with are not just about foreign nationals from outside the EU or the European economic area. The rules for EEA members are complex. If people come here to work, we have an obligation under EU law to allow them access to free treatment, but if they are economically inactive or if they are temporary visitors, we should be able to reclaim the cost of that treatment from their home country in the EEA. The fact is that we do that very poorly indeed at the moment and that is one of the things we need to change.

I particularly welcome the linking of visas to health insurance, but will my right hon. Friend explain what will happen if someone who is already in the UK is asked to pay but simply cannot? Will they be refused treatment?

No one will be refused treatment in a life or death situation. It is important that we state that up front. However, we also want to remove any expectation that people who are not entitled to NHS care are able to come to the UK and get it, and to ask whether we should be giving free NHS care to people such as foreign students who come to the UK and get it. If they went to Australia or America—our two main competitor countries—they would have to take out health insurance or pay a levy to access the local health care system. If those countries do that, I think we should do the same.

Is the Health Secretary aware that when I was in a London hospital some years ago I counted more than 40 staff from different nations? I am proud of my United Nations heart bypass. The message from this Government and many others, including the UK Independence party, is that those of a similar colour, of different colours and of different nationalities can change the bed sheets and operate, but woe betide them if they want to put their head on a pillow when they are ill. What hypocrisy.

The hon. Gentleman should do a lot better than that. He should think of his elderly constituents—people with multiple long-term conditions—who are having to wait much longer than they need to because A and Es not just in London, but in many parts of the country, are clogged up with people who may not be entitled to free NHS care because we have a system that culturally and operationally is not able to track these measures. It is in their interests that we must ensure that the NHS is available to people who are entitled to free care. When people are not entitled to free care, the point is not that the NHS is not available to them, but that they should pay for it.

I have a choice on the Lib Dem Benches between two doctors. Let us hear from the good Dr Julian Huppert.

The former public health Minister, the hon. Member for Guildford (Anne Milton), revealed in a written answer on 17 March 2011 that the sums not collected from overseas patients totalled less than £7 million a year. If we double that and double it again, as the Health Secretary suggests, that is £28 million. Private finance initiative schemes cost the NHS that much every two weeks. Which issue is more important in ensuring that we have a properly funded NHS?

There is a problem with recruitment in the NHS not only in England, but in Wales. Last year, Welsh NHS trusts tried to recruit 32 A and E consultants from the UK, but failed to do so and had to go abroad. Is there not a danger that the rhetoric in which the Government are indulging will put off the talented doctors that the NHS in this country needs?

We owe a great debt to the many talented doctors, nurses and health care assistants who come from overseas and make our NHS what it is. Nothing in our immigration laws will change that.

My right hon. Friend will be aware that the overwhelming majority of our constituents who travel abroad put in place provision to protect themselves if they fall ill. My constituents and his will be appalled to learn that we do not expect the same of foreign visitors to the United Kingdom. May I congratulate him on his initiative, which began before the Prime Minister’s speech today?

My hon. Friend is right. We have one of the most generous systems of health provision for overseas visitors of any country in the world. Most other European countries are less generous because they operate a social insurance system, which makes it much easier to collect the money that they are owed by the people who are not entitled to free care. We have to change the system here. The key thing that is wrong with it is free access to primary care, because that is the gateway into the NHS. Although primary care itself is not the most expensive part of the NHS, because of its gateway role, unless we control it, we will not get the overall system under control.

If the child of an asylum seeker who is yet to have their asylum application determined requires NHS primary care, will they still be eligible for free treatment?

I am finding it rather difficult to ask a question, because I have been rendered speechless by the chutzpah of Labour Members in not saying that what the Secretary of State proposes is sheer common sense and in not agreeing with him. I have a simple question. How will GPs know which foreign nationals are entitled to NHS care and which are not?

My hon. Friend asks a very important question. We have to recognise the pressure on GPs and must be careful not to increase the bureaucratic burden on them. The long-term answer is to have proper digital patient records. If the first thing that people are asked for when they enter any part of the NHS is an NHS number that allows the person they are seeing to look at their medical history, which could be a trigger to identify someone who should be paying for their NHS care. We are seeing whether there is a non-bureaucratic way of achieving that in the short term, while we put that technological system in place.

The Secretary of State and the Conservative party should remember that the coalition has been in power for nearly three years and nothing has happened on this issue. There are two things that he could do. He could withdraw the circular today and he could consider introducing an entitlement card that people could carry with them.

I congratulate the hon. Gentleman on his chutzpah in criticising the Government for not doing anything in two and a half years, when his Government did nothing in 13 years.

The Secretary of State has made it clear why the figure of £20 million a year is a ridiculous underestimate of the true state of affairs. He will be thanked by every British taxpayer in this country, no matter what the saving, because they are getting increasingly tired of services being accessed by people who do not have a proper entitlement to them.

I thank my hon. Friend for his comment. Of course I want to do a good job for taxpayers, but also for the 3 million British citizens who use the NHS every week and who find a service that, although the Government have protected its budget, is under increased pressure. I want to ensure that the system whereby people from other countries access those same services is one thing, and one thing only: fair.

It would be useful if the Secretary of State provided clarity and accuracy on the numbers we are talking about. The Prime Minister’s spokesperson said that unclaimed costs amount to £20 million, but the Secretary of State seems to be saying £200 million. I wonder whether he can account for the difference. Did he just add a zero?

I explained where the figure of £20 million came from, and why I believe that it is probably the tip of the iceberg. If the hon. Lady really wants to know the answer, we do not know the full extent of the abuse of NHS services because the previous Government left them in such an appalling mess.

I understand that under the European health insurance card scheme the UK paid out about £1.7 billion for Brits abroad, but claimed only £125 million back. Is that also receiving attention?

Yes it is. We are always likely to pay out more than we receive under that scheme because we have a number of pensioners who decide to retire to slightly sunnier climes and there is a cost to the UK under EU treaty law with those decisions. My hon. Friend is right to point out that just as inadequate as our failure to charge people from outside the EU when we should is our failure to collect money from inside the EU when we are able to, and we must also look at that.

The Secretary of State has clarified the Prime Minister’s figure of £20 million, but he used inflammatory language to my hon. Friend the Member for Bolsover (Mr Skinner) about health tourists clogging up A and Es. He claims that £200 million could be the tip of the iceberg, but if he does not know the figure is that not the worst example of dog-whistle politics?

If we do not know the figure, is not the right thing to do to find it out and sort out the problem, unlike what the hon. Gentleman’s party did during 13 years in office?

I congratulate the right hon. Member for Birkenhead (Mr Field), who in raising this issue is, as always, streets ahead of those on his own Front Bench.

May I thank my right hon. Friend the Health Secretary for the extra £20 million funding that the NHS in Worcestershire will receive this year, and urge him to take that agenda forward and ensure that as much funding as possible goes to the residents of Worcestershire and to addressing the kinds of pressures that we saw over the last week in A and E?

Obviously, I want to ensure that as much money as possible goes to residents throughout the country by tackling abuse, and I would not want to minimise what the issue might be in Worcestershire. I stress, however, that the biggest problem we face is in big urban centres where there are large numbers of illegal immigrants, and we must get a grip of that problem for the sake of the elderly population in those cities.

If the Secretary of State is concerned to protect NHS budgets, why is he allowing a £2.2 billion raid from the Treasury? Is that not a much more serious cut in the NHS services we can pay for in this country?

If the hon. Lady is worried about that, perhaps she might like to complain to her own party leadership, which, during Labour’s last five years in office, had an average underspend in the NHS of £2 billion.

I, too, congratulate the right hon. Member for Birkenhead (Mr Field) on his urgent question, and my right hon. Friend the Secretary of State for Health on following my private Member’s Bill, the NHS Audit Requirements (Foreign Nationals) Bill. When will that primary legislation receive Government time to start its passage through this place?

I congratulate my hon. Friend on his excellent private Member’s Bill, which looked forward to many of the problems we are trying to address. Our first step is to identify the scale of the problem. We will then identify the right legislative response, but the response will not all be legislative. That is when we will consider including it in the parliamentary timetable.

In answer to the hon. Member for Rossendale and Darwen (Jake Berry), the Secretary of State said that when someone does not have the funds, treatment will not be refused if it is a life-and-death situation. For clarity, will he will us what the threshold will be? For example, if someone has a broken leg, or if someone needs another treatment that requires hospital admission, and they do not have the funds, will treatment be refused under his scheme?

The hon. Gentleman will be relieved to know that that will be a matter for clinicians, not politicians.

I cannot tell my hon. Friend the answer except for one detail: my two children were not born to a mother from the EU.

The Secretary of State has explained that the July guidance was from an independent body and in line with the existing rules. Who wrote the existing rules? Will he confirm that he will change them?

The rules existed for 13 years under the Labour Government, who did absolutely nothing to change them. We are tackling the problem. If Labour Members had any grace, they would thank us for doing so.

When I tabled questions last year, I was told that we collect £51 million a year for treatment from EU countries, but that they collect £451 million—nine times more—back from us. Is this an issue not of immigration, but of coding, charging and collecting?

My hon. Friend might be right—we need to look at that—but as I have told my hon. Friend the Member for Dover (Charlie Elphicke), one factor is that a number of our pensioners retire to sunnier climates, which leads to that imbalance.

Is the Health Secretary aware that general practitioners have been calling for the measures to be taken for some time? The Bedfordshire and Hertfordshire local medical committee wrote to me some time ago expressing its concerns that overseas nationals were coming here for expensive operations. It will be very pleased at what he has done today.

My hon. Friend speaks wisely. NHS professionals on the front line have been conscious of the problem for a long time, but have been frustrated that nothing has been done. I therefore hope that they very much welcome today’s announcement.

Now that Labour has realised it is legitimate to discuss immigration, does my right hon. Friend agree that it is time for the Opposition to acknowledge that legitimate charges by the NHS to EU and other residents were not collected properly for 13 years; that identifying the £20 million as the tip of the unpaid iceberg is the right thing to do; and that a tightening of procedures on debt collection will be welcomed by my constituents and fair to all our constituents throughout the country?

Absolutely. It is astonishing that the Labour party complains in one breath about pressures on A and E, and the next moment tries to make light of the serious attempts the Government are making to get a grip of the problem.

Does the Secretary of State agree that the vast majority of people in the UK will welcome these long-overdue proposals? Will he explain what he will do to ensure that those who are denied treatment because they are here illegally and not entitled to it cannot simply slip over the border to Wales or Scotland, which, unfortunately, are in the throes of an NHS run by socialist Governments?

We will work closely with the devolved authorities to ensure we have a co-ordinated response to the problem, but I agree that today’s announcement will be welcomed by the vast majority of people in the country, who will be astonished that the Labour party, even now, seeks to minimise the problem.

Given that the UK has one of very few genuine free-at-the-point-of-need health care systems, does my right hon. Friend agree that, without his sensible reforms, the UK will continue to be seen as the destination of choice for anyone around the world seeking high-quality, free medical treatment paid for by the UK taxpayer?

I agree with my hon. Friend. It is because I support the principle of free-at-the-point-of-use health care that I do not want anything to undermine it, and abuse of the system by people who are not entitled to free NHS care is the single thing that would most shake the public’s trust in an important part of what the NHS has to offer. That is why we must tackle this problem.

The Secretary of State rightly recognises that accident and emergency is a special case, but when I broke my fingers in Brussels I was asked to pay by credit card at the end of my treatment. A lot of people who present at A and E have non-life threatening conditions. Is that something we could do here?

I understand my hon. Friend’s sense of unfairness at being asked to pay for her treatment by credit card, when we do not do that to foreign nationals who are treated in the NHS. I do not, however, want the NHS to become a service where the first question people are asked relates to their credit card or cheque book. If we are going to protect that much-cherished principle of NHS treatment, we need to get a grip on the kind of abuse that has run unchecked for far too long.

Does the Secretary of State agree that the House is divided by two schools: the Opposition, who believe that the NHS should not charge anyone, which is why they did nothing for 13 years; and Government Members, who believe that foreign nationals who should pay, must pay.

I agree, and nothing we have heard this afternoon will give the British public any comfort at all that the Opposition get this problem.

I welcome my right hon. Friend’s statement. Does he agree that the previous Government’s failure to tackle health tourism encouraged overseas visitors to abuse our NHS?

My hon. Friend is right. One reason why we are tackling this problem is not just the health agenda we have been discussing this afternoon, but that abuse of NHS services fuels broader immigration problems. That is one of the core reasons the previous Government failed to get a grip of net migration in particular.

Calderdale and Huddersfield NHS Foundation Trust spent £305,341 on interpreter services between 2009 and 2011. Will my right hon. Friend include the costs of translation services when working out the costs of health tourism?

I would want to be careful to discriminate between the needs of British citizens and people who are entitled to free NHS care who have not had the education or support they need to learn English but who should still continue to receive free, high quality NHS care, and foreign nationals who are not entitled to free NHS care and who should pay the cost of any translation required.

My constituents are absolutely furious that non-entitled foreign nationals are effectively getting free access to our NHS, and I welcome the steps my right hon. Friend is making to tackle this issue. Will he ensure that Her Majesty’s Government fast-track legislation, with an announcement in the Queen’s Speech, and challenge the Opposition either to bring down or pass that legislation in the next parliamentary year?

I have visited Kettering hospital, and I know just how hard its front-line professionals work and the pressures they are under. All I can say to my hon. Friend is that the Leader of the House of Commons is sitting here and has heard what he has said, and I would certainly support the early introduction of legislation on this matter.