(10 years, 9 months ago)
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The Earl of Listowel
“Pregnancy exemption
Any—(a) restriction on eligibility for services, or(b) charge,in this Part shall not apply to any person who is pregnant.”
The Earl of Listowel (CB)
In moving Amendment 48, I will speak to Amendments 55, 63 and 65 and support my noble friend Lord Patel’s Amendment 60. I apologise for not having been able to take part at Second Reading. Perhaps it would be helpful to the Committee if I paused for a moment.
Baroness Anelay of St Johns (Con)
My Lords, the noble Earl, Lord Listowel, is trying to introduce his amendment and I would ask that noble Lords leave quietly. That was quite a din. I also remind noble Lords that, when they leave, they should not walk in front of the speaker. It not only drowns him out, it means we cannot even see him.
The Earl of Listowel
I am most grateful for that intervention. Amendment 48 would exempt pregnant women from all charges and penalties associated with Part 3, particularly with regard to health charges and concerns for landlords about having tenants who might not be legal migrants. I want to take pregnant women out of this picture.
I recognise the difficulties that the Government face in terms of immigration. I grew up in Hampstead but I have lived and worked near Bermondsey, and I know that for the people of Bermondsey and other similar areas there can be more challenges due to immigration than in places such as Hampstead, around schooling and access to the health service but particularly around housing. There are real concerns and the shortage of housing can be a cause of social tension.
This, too, is a knotty political question, but if the Government and Opposition could come to some consensus about how to provide enough social housing and affordable housing for our people, many of these tensions might be far less acute than they are today. I know that is a great challenge but it relates to this issue and the concerns of our people about migration.
Perhaps it is helpful to think about how maternity has a certain sacred association. If one wanders around the Sainsbury Wing and looks at the earliest paintings there, one sees paintings from the 13th century of the Madonna and child, and nativity scenes. Respect for the mother and child during that very important period at the beginning of a family is at the heart of our Christian faith. It is not too surprising that France, Spain and Portugal—some of the Catholic countries—exempt pregnant women from any charges for accessing their health services. It points to the wisdom of the great faiths, as we increasingly realise how vital the very earliest months of a child’s life, from conception through the first two years of life, are to the successful later development of children.
Indeed, the right honourable Iain Duncan Smith did very important work concerning early intervention with families. Graham Allen MP, who worked with him in that endeavour, has set up the Early Intervention Foundation, which aims to raise awareness of the crucial period between conception and two years of age, and perhaps a little bit beyond that. Frank Field MP and Andrea Leadsom MP have set up the All-Party Parliamentary Group for Conception to Age Two—The First 1,001 Days, to really focus our minds on this crucial time in a child’s development. It takes several years for a child to grow into the physical stature of an adult but the brain is developing extremely rapidly in the first months of life and achieves its main development by age four. It is crucial to think carefully about how we treat mothers and their very young children.
I should have said something about newborns in my amendment. I talked only about pregnant women, but I hope that the Government will also think about mothers with newborn children within the first two years of life.
On several occasions I have had the privilege to speak to mothers in temporary accommodation through the Barnardo’s Families in Temporary Accommodation project. What came through particularly from their stories was the sense of isolation that they experienced and how difficult it was because of their temporary accommodation—they may be placed a long way from family or anybody of their ethnic group.
Baroness Smith of Basildon (Lab)
My amendment is the second in this group and is the only one that deals with domestic violence. I thought that it would be helpful to include the amendment in this group rather than have a separate debate on domestic violence.
I want first to turn to the housing provisions, which require landlords to check the immigration status of those to whom they let. I said at Second Reading that we have serious concerns about these measures and we have tabled a number of amendments to the relevant part of the Bill. I shall not go into detail here because it is a separate debate for, one hopes, later today.
I want to put on record our concern about the workability and what I will refer to—I hope that this is accurate—as the unintended consequences of the provisions. The Government should be aware of the impact of the proposals on vulnerable persons, such as pregnant women and many others, as the noble Earl, Lord Listowel, highlighted. The amendments in this group highlight the concerns about those issues.
Not everybody in life is well organised, not everybody has all their documentation up to date and not all landlords will be able to fulfil—or, perhaps, even understand—all their obligations under the Bill. People can make mistakes. I think that I am a well organised person, but can I say that I have never forgotten to pay a bill or never missed my MoT date? Of course I cannot; we all make mistakes.
We learnt that when the former Immigration Minister, Mr Mark Harper, had to resign. Even with all his good intentions and integrity, wanting to obey the law and trying to do so, he still made a mistake. There are great concerns about those whose lifestyles may be a bit more chaotic, or those who are here legally but do not have the right kind of documentation. That could include pregnant women and victims of domestic violence. They might end up being refused accommodation as a result of these measures because landlords do not want to take the risk of making a mistake. The danger is that that could result in them falling into the hands of rogue landlords or becoming homeless.
I hope that the Minister can be clear on whether those issues were considered when discussions were held on including the provisions in the Bill. If they were considered and the Government are aware of all those consequences for vulnerable groups, how will they address them—in particular, under this group of amendments, pregnant women and victims of domestic violence?
Most of the amendments referred to the health charges. There is a lot of confusion about the measures in the Bill and other measures announced by the Government. They must recognise that they must take responsibility for any confusion. The Government’s rhetoric and the sweeping statements that we have heard about what they call health tourism add nothing to the seriousness and quality of the debate. Again, I do not want to go into the wider issues—we will have a wider debate on health charges later, and I will raise the bulk of the questions and concerns that we have then—but I want to ask a few questions on specific issues raised by this group of amendments.
I want to be clear from the outset that we agree with the principle of a one-off health surcharge. It is not unreasonable that those who use the NHS contribute to it. My understanding is that all those who have paid the charge would then have full access to the NHS, but the Government’s consultation document then excludes a few treatments. That is not in the Bill, but it starts to cause confusion. In particular, the consultation document states:
“It may be appropriate to build in a very limited set of excluded treatments for which specific charging should still apply. These might include any or all of the following”.
One of those in the list is services for pre-existing pregnancies. As I said, that is not in the Bill, and that is why I want some clarification. As I read it, that seems to mean that women who have paid the visa charge and come to the UK already pregnant—presumably at whatever stage of pregnancy, whether they know about it or not—will nevertheless have to pay for treatment related to their pregnancy. Is that all treatment or some treatment? We just do not know, and the Bill does not provide any clarity on that. I wonder whether when those women get their visas they get a pregnancy testing kit at the same time to check whether they are pregnant.
A number of groups are to be exempt from paying the health surcharge on humanitarian grounds. We totally support that; it is absolutely right. The Department of Health said that that would include refugees, asylum seekers and victims of human trafficking—presumably, whether or not they are pregnant. I know that victims of trafficking will now be debated in a separate group, but I want to press the Minister on how this will work in practice, as there will be cases when they will present to the authorities only when they are pregnant. Trafficked women will not, by definition, have paid the charge. The UK Human Trafficking Centre suggested in its 2012 baseline survey that more than half of all trafficked victims were not referred to the relevant authorities for assessment, so how will we know who they are?
Specifically on domestic violence, what will happen to women who are trying to escape a violent relationship and who, in fleeing the home, are left without any evidence of their entitlement and no information on their immigration status? They may be UK citizens or have indefinite leave to remain but do not have the documentation. They have fled their home because of violence and to protect themselves and their children. Women who flee a violent partner often do so at the time of the most extreme circumstances that they can face. They will not have time to pack up their belongings, hunt for their passport, pack it into their bag, fold up their documents and bring those out with them. They are going to flee the home to protect themselves and their children so when they present for housing they will, if they are fortunate, be placed in a hostel or refuge. If I am correct, the Government are quite rightly exempting that. However, others will just run and, having run, will try to find suitable accommodation.
With the financial difficulties being faced by women’s aid groups across the country—I declare an interest in that I am patron of Basildon Women’s Aid—supply cannot always meet demand. What do the Government expect these women to do? How will they find accommodation? Will a sympathetic landlord be forced to turn them away if they do not have their documents and, if they are pregnant, where are they going to give birth if they have been turned away by a landlord? Where will their home be? A number of questions are being asked today, and I think that there will be many more from other noble Lords who have amendments in this group, about the implications of Clauses 33 and 34 for pregnant women and victims of domestic violence.
I have spoken to the Minister about this already, so he is aware of my concerns. However, we need far greater clarity about what is in the scope of the Bill and what has been just government rhetoric or other issues which the Government pretend they will take later. What is going to happen and how will it work in practice? I would find it quite helpful if the Minister could help me understand the position of someone who is here legally but who has not paid the visa surcharge—because they are here at present and that surcharge has not come in—and does not have permanent or indefinite leave to remain. What is their position regarding healthcare? I am assuming that transitional arrangements will make provision for that but I am not clear on how that will work in practice. If the Minister can shed any light on that, it would be extremely helpful.
Baroness Cumberlege (Con)
My Lords, I have two amendments in this group—Amendments 59 and 63. I declare my interests, which are in the Lords’ register.
We received a very interesting letter from my noble friend Lord Howe over the weekend. His letter explains that Clauses 33 and 34 are designed to break, or perhaps put a stop to, the activity of health tourism. It is absolutely right that we should do that. Having read his letter, I understand that estimates suggest that between £70 million and £300 million of costs—it seems to be rather a large gap—are attributed to people who deliberately travel to England to get free healthcare because their treatments are so expensive in their country of origin. In no way should we entertain health tourism; it should be detected and the individuals suitably charged. The NHS, as we know, is enormously generous and supported by us all through our taxes. The whole purpose is that we should contribute, through our taxes, to the well-being of our own country’s health.
I have had a long-time interest in maternity services. As the noble Earl, Lord Listowel, indicated in introducing his proposed new pregnancy and maternity clause, there really are few things more important to a woman than bringing a new life into the world. It is a journey of dramatic physical, psychological and social change; of becoming a mother, of redefining family relationships and in taking on the long-term responsibility of caring for and cherishing a newborn child. If the needs of child-bearing women and their babies are ignored, then not only are the physical, social and psychological long-term effects damaging to those concerned but the economic implications for the country are considerable.
Lord Patel (CB)
My Lords, I shall speak to Amendment 59, which stands in the name of the noble Baroness, Lady Cumberlege, and to Amendment 60, which stands in my name. I have added my name to Amendment 59. I also strongly support Amendment 63, which stands in the name of the noble Baroness, Lady Cumberlege, and other noble Lords. I would have added my name to it, but another Lord Patel—the noble Lord, Lord Patel of Bradford—beat me to it. I think the priorities were wrong there, but never mind. It just shows that Amendment 63 has wide, cross-party support in the House.
I declare my interests. I am on the specialist register of the General Medical Council as an obstetrician. I also hold the position of professor of obstetrics at the University of Dundee. The noble Baroness, Lady Cumberlege, gave a long list of reasons why pregnant women should be seen early in pregnancy, and I could add another 500 or more, but I do not want to recite a textbook of obstetrics and antenatal care. It is important that every pregnant woman is seen as early as possible during pregnancy if we are to prevent problems occurring later in pregnancy for her and her child’s well-being. It is important that she is seen early so that problems that are occurring are identified early and can be treated early to prevent serious complications developing later. As the noble Baroness, Lady Cumberlege, said, in maternal mortality reports, it is the women who are seen late in pregnancy who develop the most complications and even die. Hence anything we do that will prohibit or prevent women from being seen early in their pregnancy will be wrong.
As for health tourism, the visitors are not part of this levy or these charges. It is likely that the so-called childbirth tourism occurring here, often referred to by some hospitals as the “Lagos shuttle”, is about visitors and not those seeking to enter this country on different visas. I therefore hope that the Minister will look again at why pregnant women are included in the levy and charges.
My Amendment 60 includes not only persons who are pregnant but also children. To clarify, I included children under 18 because, currently, children under 18 in this country are exempt from NHS charges. Of course, I realise that, in terms of risk, children under five years old are different from children aged five to 12 or, for that matter, 12 to 18. As no other noble Lord is likely to speak about children, although the noble Earl, Lord Listowel, referred to them briefly, I intend to speak at length only to demonstrate how important children are and what harm the levy, or imposing charges on children, could possibly do.
My amendment would exempt children from the migrant health levy when they apply or are included as dependants in an application for leave to enter or remain. The levy is to apply generally to visa applicants who are students, workers or families, but not visitors. Currently, it is intended that payment of the levy will provide the applicant with free access to all NHS services for the duration of his or her visa. As the noble Baroness, Lady Smith, said, we need clarification about whether the levy means that they will get all NHS services free of charge. There is a lot of confusion about that. For instance, Clause 33(4) makes it clear that there is no guarantee that restrictions on access to particular services will not be introduced. Clause 33(3)(e) includes a power for the Secretary of State to make exemptions from the levy. However, it is not clear in the Bill what the consequence of such an exemption would be. Without more, it appears that a charge would be made where a child exempted from the levy needed to access NHS services, save for any services which regulations may exempt from charging.
As to which services charges will apply, the intention is that this will include primary and secondary care services, including accident and emergency services. GP consultations will be free, although it is unclear whether any treatment that may be delivered by or via the GP will be free. Treatment for specified communicable diseases and sexually transmitted infections will be available. It is yet to be decided whether any, or how many, mental health services will remain free. There is a great deal of doubt.
The Department of Health response to last year’s consultation on migrants’ access to NHS services recorded,
“widespread support for exempting all children, not just those in local authority care, from charging”.
However, the Government then concluded:
“We do not intend to establish an exemption for children as we believe this poses a significant risk of abuse by visitors seeking treatment for children … Vulnerable children, such as victims of trafficking, those seeking asylum, and migrant children in local authority care currently receive free healthcare and will continue to do so. We will listen to arguments about how best to cover other vulnerable children who might otherwise be denied treatment”.
Can we know what this group of “other vulnerable children” will be? To me, all children of a certain age are vulnerable.
Baroness Barker (LD)
Clause 33 enables the Government to introduce a health levy. The noble Baroness, Lady Smith, said that her Benches support it in principle; on our Benches, we support it as the least worst of a number of options, none of which we particularly favour. We think that a health levy is preferable to requiring people who come to this country to take out forms of private health insurance that do not meet their needs and are considerably more expensive. However, having said that a health levy may be one way of generating income for the NHS that we can support, like other Peers we have considerable reservations about what the effect will be in practice—and, in particular, what the deterrent effect will be on people who require health services. We will go on in later groups of amendments to discuss that in greater detail, but in this group noble Lords have focused first and foremost, perhaps not surprisingly, on pregnant women and children.
The noble Earl, Lord Listowel, in his introduction was almost biblical in his references to our consideration for expectant mothers and children. I am not as spiritual as he is—I am much more practical. I would say that one of the haunting images of last year was that of the asylum seeker who drowned in the boat off Lampedusa in southern Italy, who was found to be giving birth at the time. When I listen to people talking about maternity and health tourism, time and again I go back to that woman and what must have been going through her mind, and what her life must have been like, to be pregnant and in that position. That is just my disposition towards our general discussion.
The noble Baroness, Lady Cumberlege, introduced her amendment in her characteristically thoughtful and well researched way. She, too, referred to the letter of the noble Earl, Lord Howe, of 6 March, in which he explained the thinking behind this Bill from the point of view of the Department of Health. I, too, wanted to focus noble Lords’ attention on the statement that he made. He said that there was “widespread evidence” and,
“a cost of between £70 million and £300 million from people who deliberately travel to England to get free NHS treatment—so-called ‘health tourists’”,
of which those seeking maternity treatment were most prominent. There is some difference between £70 million and £300 million. My first question to the Minister is: can he explain the range? Even if he can, £300 million in terms of the overall NHS budget is minuscule. Consequently, when we are doing our job in this House as we should, which is to consider not just the immediate cost but the overall impact of a charge, we have to do it in recognition of that fact.
I should like the Minister to explain exactly how the Department of Health arrived at that estimate, particularly as the small charity, Médecins du Monde—Doctors of the World—conducted research across the European Union and discovered that there is no higher rate of migration to this country under our current system of charges than to places such as Germany. I simply repeat, as I did at Second Reading, that I have no problem with our making a fundamental change to our health policy provided that we do so on the basis of proper evidence and not the cynical opinion of newspapers.
Amendment 64A in this group stands in my name. Other amendments in the group, which I support, refer to pregnant women. Mine refers to women who are pregnant or require postnatal treatment. We afford postnatal services to those who are ordinarily resident. We do so routinely for women who do not have problems, who also have access to health visitors to ensure that they and their children are functioning well in the first few weeks of the children’s lives. We afford these services to women who have problems which may not be very significant but which we know are important in the development of their children—for example, women who are having trouble breastfeeding or women who are suffering from postnatal depression. We also extend treatment to women who have suffered traumatic deliveries and need surgery following deliveries that have not gone well. That is what we do for our own people because it is the right and decent thing to do. I should like to think that in future, no matter who a woman is or what her financial status is, she, too, will be afforded such treatment.
Finally, I thoroughly support the amendment of the noble Lord, Lord Patel, which mentions children. I pay my taxes to live in a country where the first question that a doctor asks concerns what is wrong with a child and what treatment they need, not who their parents are. Our wish is to retain that as far as we possibly can.
Baroness Lister of Burtersett (Lab)
My Lords, I support the amendment on domestic violence in the name of my noble friend Lady Smith of Basildon. She has made the case for it, so I will not repeat that, other than to point out that this amendment is totally consistent with the Government’s own action plan on domestic violence and builds on the destitute domestic violence concession. It is a very modest amendment, which would simply guarantee a period of safety, with access to services and benefits, after the breakdown of a relationship because of domestic violence. I hope I am not being naive when I say that I am confident that the Government will support this amendment, given that it is so consistent with their own policy.
I also support Amendment 60, in the name of the noble Lord, Lord Patel. I am very glad that he introduced an amendment on children to remind us of the potential effects on children of some of these changes. I draw noble Lords’ attention to what the Joint Committee on Human Rights, of which I am a member, had to say on this matter. It referred to the concerns that,
“arise about the possible impact on children of the provisions in the Bill which extend charging for NHS services … Extending charging to migrants not previously charged for accessing health services, and extending the range of services for which charges apply, are likely to have a deterrent effect on accessing health care, which in turn is likely to have a particularly detrimental effect on the children of such migrants”.
I will not go into the full detail but our recommendation was that to meet these concerns,
“about the impact of extended charging for health services on children’s health, we recommend that new guidance be issued specifically on the s.11 Children Act duty”,
which applies to the NHS,
“explaining to front-line decision-makers in the health sector exactly how that duty applies in the context of extended charging for NHS services”.
I should therefore be grateful if the Minister would say what the Government’s response is to that.
Baroness Tonge (Ind LD)
My Lords, I support all these amendments—in particular, Amendment 63, to which I have added my name. Unfortunately, due to circumstances, I was not able to be present at Second Reading, but I support these amendments because I worked in the health service for more than 30 years, particularly in women’s health services, implementing, supplying and managing those services. My late husband worked in the health service for more than 40 years.
The first point that I would like to make from that experience and that of many colleagues with whom I am still in touch concerns health tourism. It really is most extraordinary that this term is bandied around to scare people that the health service is being misused by countless numbers of people who really should not be here. It is the same old thing that appeals to Daily Mail readers: these people should not be here and they must not access our facilities. Yet, in all that time neither I nor my husband ever came across health tourism and nor have I ever heard colleagues talk about it. I reinforce what the noble Baronesses, Lady Barker and Lady Lister, said: the letter from the noble Earl, Lord Howe, was extremely woolly in that department. I think that the so-called evidence for this is really just anecdotal.
Perhaps I may say a few words about the noble Earl, Lord Howe. He writes a wonderful letter and he is the most emollient man. I think that if I were on my deathbed and the noble Earl appeared, I would rise and feel well again. He has that ability. He is in the wrong profession—he really should be out there tending the sick because he makes us feel happy and cured. However, being a cynic, I do not believe all that he says, and I hope that sometimes he does not believe it either.
So let us sit back and think really hard about whether health tourism exists. In any case, if, through some medical sleuth, we identified that there were health tourists, would the problem be large enough to make a difference? Would it really bring in that much more money to the health service?
In passing, my late husband was at St Thomas’s Hospital, which is alleged to have experienced the “Lagos shuttle” in relation to maternity care. St Thomas’s and the Royal College of Midwives have denied this, so I question whether this should be used in any way as evidence for charging pregnant women if they want to come to this country as migrants.
My second general point is that one of the reasons why I support Amendment 63 is because it points out awfully well how terribly difficult it will be to make any of the charges. How will that be done? I have been out of the health service for quite a while and I wonder who will implement this? If a pregnant woman says, “I’m pregnant and need antenatal care”, presumably a layer of bureaucrats will have checked her bit of paper. However, what if she does not have a bit of paper, forgot to get it, has lost it or does not speak English? She may have high blood pressure or be carrying twins—we will not go into all the medical obstetric possibilities that the noble Lord, Lord Patel, mentioned. If so, will we really deny the woman care? Doctors and nurses go into their profession because, I hope, they possess a certain amount of compassion, and want to help people. We have to ask patients myriad questions before we even start asking medical questions about their health. Are we to add another layer of questioning? How will we have time to do it? We do not have enough doctors and nurses. They are all overworked, so how will we implement this? Again, will it be financially worth it to create all that distress and bureaucracy?
I know that I have made general points but I say finally that I want to support all noble Lords who have pointed out that if we fail to give proper antenatal care to a pregnant woman we are failing her and her future health, and we are failing the baby or babies she is carrying and their future health. That is not only a double human tragedy but it is denying them their human rights. It is also setting up far more work and expense for the health service in the future if it is not dealt with properly. I beg the Minister to reflect on this between now and Report and to withdraw this awful provision.
Baroness Masham of Ilton (CB)
My Lords, this list of important amendments deals with the health of some very vulnerable people. I have put my name to Amendment 65, but several deal with exemption of payment for pregnant women if they are unable to pay. I do not know which of the amendments is most appropriate but I hope that the Minister will accept the spirit behind the amendments and bring forward an acceptable amendment on Report.
Charges at the point of care create risks that women will not attend care, will attend late in their pregnancy or will be denied access to care because of inability to pay. This can prevent midwives identifying and treating health conditions early in pregnancy which, in turn, can lead to significantly worse health outcomes for vulnerable, migrant women. NICE has acknowledged this and recommended that care providers take additional measures to promote early engagement with maternity services. FGM reversal is best undertaken prior to 20 weeks of pregnancy. Charges at this point of care can result in higher costs later to the NHS. Pregnant women who are HIV positive need treatment so that their babies are born free of HIV. They should not be put off seeking care. Delayed or no antenatal care can lead to complex interventions at a later date. For example, identifying and treating urinary tract infections during standard antenatal care prevents a woman developing a kidney infection that can result in premature birth which can be very expensive to the NHS. I hope that the Minister will do his very best to agree to some of our points.
Lord Harries of Pentregarth (CB)
My Lords, I have listened carefully to the debate and support the general thrust of all the amendments. However, like the noble Baroness, Lady Masham, I am not clear which of the amendments particularly meets the bill. I hope the Government will indicate not only whether they are receptive to the general thrust but which amendments are particularly inadequate. I hope the Minister will address the question posed by the noble Baroness, Lady Tonge, of what exactly is meant by the phrase “health tourism”. What is the evidence that it exists?
Baroness Finlay of Llandaff (CB)
My Lords, this has been an important debate and I declare all my health interests. In speaking briefly, I will not reiterate the points made by the noble Baroness, Lady Cumberlege, and my noble friend Lord Patel but they are incredibly important.
When the Minister comes to reply, perhaps he will give the figures in respect of the actual cost of antenatal care versus the actual cost of complications. Let us not forget that a massive haemorrhage in labour or a massive problem with obstructive labour will cost a great deal of money in emergency treatment when, if they had been picked up much earlier with a simple ultrasound examination, the problems could have been avoided. Will the Minister give the costs and the research evidence behind the reason for the Government not exempting pregnancy and children? Will he say what discussions the Government have had with the royal medical colleges and the Royal College of Midwives, in particular, over the background to this measure and its implementation? For doctors, nurses and midwives trying to implement it on the ground it will be a nightmare.
What do the Government intend to do to monitor the effects of the measure—in other words, how will they audit it—when and if they proceed to implement the Bill as it is currently drafted? Will that audit include a cost of the complications that would have been avoided in the event that pregnant women had had appropriate antenatal care?
There is a great deal of evidence behind this. From all the amendments that have been tabled today it seems evident that a consolidated and focused amendment will be brought back on Report. Like others who have spoken, I believe it would be most sensible for the Government to listen today and take the evidence on board, rather than push the House to determine its view.
Lord Avebury (LD)
My Lords, I should like to add a few words to what my noble friend Lady Barker has already said about Amendment 64A which, unlike some of the other amendments in the group, covers postnatal as well as prenatal treatment.
We had a meeting with representatives of the Royal College of Midwives, as mentioned by the noble Baroness, and Maternity Action on 27 January and we have taken note of the strong arguments for exempting these patients from charging, as I hope the Minister will have done by the end of this debate. As has been said repeatedly, there is no official estimate of the net cost to the NHS of non-EEA short-term migrants needing maternity treatment once those exempt from charging are removed from the equation. Neither in the Government’s briefing nor in any other source have I been able to find a reliable estimate of the volume of alleged maternity tourism. However, as has been said, anecdotal evidence exists, of which the Minister’s letter is an example.
This all seems to have arisen from an assertion by Sky News that 300 women had been stopped at Gatwick but then had to be admitted because they were assessed as being more than 36 weeks pregnant and therefore unable to travel back to their countries of origin. This information was said to have come from a government report, but no title or reference was given. The noble Baroness, Lady Cumberlege, quoted the letter from the noble Earl, Lord Howe, giving a wide range of estimates of the volume of health tourism generally but not maternity tourism in particular. All it had to say on that subject was that maternity tourism formed a large proportion of the total value of health tourism. Surely the answer to that problem is for the Government to stipulate that airlines flying pregnant women to UK destinations should be required to obtain certificates of the length of pregnancy from doctors they can trust, and for carriers that bring women who are more than 36 weeks pregnant to the UK to be subject to fines. That should not be too difficult because the alleged maternity tourists are said to come from a limited number of destinations. When my noble friend the Minister comes to reply, I would like him to make some comments about that idea.
At the other end of the spectrum from the Sky News report was an article about a woman whose case was reported in the Guardian. She had been living in the UK as the wife of a British citizen for seven years, but for some reason not explained in the article had evidently not obtained indefinite leave to remain. Having paid Lewisham Hospital £5,000 for maternity services in regard to care during and after her first child’s birth, she was terrified of going near the NHS and was expecting to give birth without medical supervision because she and her husband were still paying off the bill for the first child.
My noble friend Lady Tonge asked about the denial of treatment for women who present themselves as maternity patients but cannot satisfy the health authorities that they are legitimately entitled to those services. Surely the answer to that must be that the delivery of the services should come first and the ascertainment of the woman’s right to treatment dealt with afterwards. I cannot imagine that any clinician would say that they would not provide maternity services for a woman in the early stages of pregnancy, and that may be the answer to those who say that complications arising from a variety of serious causes might result from the failure to treat those who are in the early stages of pregnancy. I hope that I am right in saying that this will not happen because of the first duty of clinicians, mentioned by the noble Baroness, Lady Lister, to treat patients who come before them.
Baroness Tonge
Will the noble Lord give way? I appreciate his point, but if someone gives a patient the benefit of the doubt for antenatal care and it then turns out that they do not have an entitlement to treatment, do they then say that the patient is not going to get any more antenatal care?
Lord Avebury
My Lords, it has been the case in the past that people who receive services to which they were not entitled incur a debt. I believe that something like two-thirds of the charges levied on these people lie on the table because they cannot be recovered.
Baroness Tonge
As I am sure my noble friend is aware, pregnancy goes on for nine months. It is not a short intervention which is treated and the patient then goes away; it is an ongoing thing that includes postnatal care and goes on for a long time, as the noble Baroness, Lady Barker, pointed out. This is a long-term treatment and it is important that it should be so. Perish the thought that treatment is cut off mid way.
Lord Avebury
No, what I was saying is that I hope that the treatment would be given irrespective of the woman’s entitlement while checks are being made to see whether she is a valid patient of the NHS or is someone who should incur the charges. However, if the charges do fall on the woman, I hope that they will simply lie on the table, as obviously a substantial proportion of the costs of treatment of migrants has done in the past. From the official figures given by the Department of Health, I think it was two-thirds of the charges incurred—not just by pregnant women but by persons who were not entitled to treatment presenting themselves to the NHS. In no case that I have heard of were patients denied treatment, but the charges piled up and the debt was left there on the table. I do not know what the mechanisms for recovery will be under this system, and perhaps the Minister will deal with that point in his reply.
I assume, and want confirmation, that no woman would ever be denied treatment, but if it was ascertained subsequently that she was not entitled to it, the debt would be recorded somewhere. Whatever steps the NHS might take to recover it would be fair enough, but if it could not be recovered, like so many other debts which have been incurred by migrants generally in the past, would it be written off to the NHS? I would like reassurance from the Minister on that point.
Undocumented migrants such as overstayers and failed asylum seekers, of whom there are estimated to be half a million, are unlikely to be able to pay for maternity or indeed any other medical services. If such people work, they are on or below the minimum wage and are now likely to become unemployed with the tightening up of checks by employers on their right to work. Health authorities may invoice patients from this group, but can the Minister say what proportion of the debt is recovered and whether there is anything in this clause, or indeed in the Bill as a whole, that will make it easier to collect the money? Will they be able to transfer the debts at a discount to a debt collector, and will they be any better off than they would have been in the past before this clause was enacted?
The Earl of Listowel
My Lords, in listening to my noble friend Lord Patel’s concerns, which I share very strongly, about children and the charging of children, it occurred to me that there might also be an issue about the immunisation of children. If significant numbers of children do not get immunised, that might pose a threat. I would appreciate the Minister addressing that question in his reply.
The Parliamentary Under-Secretary of State, Home Office (Lord Taylor of Holbeach) (Con)
My Lords, this has been a very full discussion about all aspects of healthcare and healthcare charging, some of which lie within the provisions of the Bill and some of which lie way beyond it and are actually part of the Department of Health’s consultation. I guess there are two ways of dealing with this debate: I can give either the short answer or the long answer. I have chosen to give the long answer—I hope that noble Lords will indulge me—in the hope that I will be able to disabuse them of some of their anxieties and reassure them. I am very mindful of the kind words from the noble Baroness, Lady Lister, but I am also slightly anxious as a result of the description of my noble friend Lord Howe. I am equally concerned to try to be as upfront as I can be about what the Bill provides for and to reinforce my noble friend’s letter, which noble Lords will have received, which seeks to place measures in this Bill in the context of wider health service charging.
Perhaps it would be helpful to provide a brief reminder of the intentions behind Clauses 33 and 34. I will refer to my noble friend Lord Howe’s letter because it sets out the context for these provisions, which is the Department of Health’s wider programme of work on migrant access and financial contributions to the NHS. Likewise, I want to reassure noble Lords that, first and foremost, the NHS is, and will remain, free at the point of delivery for permanent residents. But it is a national service, not an international health service. We believe that migrants should have a form of access to the NHS that is commensurate with their immigration status. That is our policy position.
Baroness Masham of Ilton
Does the Minister agree that they should be working together in maternity cases? It is health but it is immigration as well.
Lord Taylor of Holbeach
I hope that I will be able to go on and talk about these matters when I address the specific amendments. I hope that when I have concluded my remarks, the noble Baroness will feel that I have indeed satisfied her in that respect. I understand the vulnerability of pregnant women and the care that is needed to ensure that both mother and child have healthy prospects.
The health surcharge is designed to ensure that legal migrants make a fair contribution to the NHS, commensurate with their immigration status. We intend for it to be applied fairly and without unintended consequences. As I have just said to the noble Baroness, Lady Masham, pregnant women should not be adversely affected—I listened with great care to the noble Earl, Lord Listowel, and to subsequent speeches on this subject. However, it is important to consider the safeguards already provided in the Bill.
In respect of the provisions relating to landlords, there are exclusions from the restrictions in accessing accommodation at Schedule 3 to the Bill to protect the vulnerable. Local or housing authorities providing accommodation in discharging a statutory duty—for example, under national assistance or children’s legislation—are not subject to these restrictions.
Asylum seekers and failed asylum seekers who face recognised barriers to return will be authorised to rent property by the Home Office, and the department will continue to support destitute applicants. Accommodation for vulnerable individuals, such as hostels for the homeless and refuges for victims of violence, will also be exempt from the checking requirements—I mention these because the noble Baroness, Lady Smith, rightly expressed concern about the vulnerable and I shall address her amendments later.
We need to consider the checks that would be required by some of the amendments. These would be intrusive; indeed, it would be objectionable to ask all temporary female migrants of childbearing age if they were pregnant and to verify that information. How could the Home Office or a service provider establish that an individual was indeed pregnant rather than merely seeking to circumvent the rules? Rather than a simple check of documentation, which is what the Bill provides for, inquiries would need to be directed to the individual’s health provider. We must also consider the unintended distress that such a practice could cause. What if a woman was reluctant to reveal a pregnancy? What if she suffered a miscarriage while her visa or other applications were being considered? She would no longer be exempt; she would need to tell us of her loss at a time of great distress. The more one looks into the detail of this and the practical application of the policy, the more the intrusive nature of these amendments becomes clear.
Some of the amendments would allow pregnant women who were illegal migrants to rent accommodation, open bank accounts and hold driving licences. As such, they would help them establish a life in the UK. However, they would also create a dangerous loophole through which illegal migrant women might be encouraged or pressurised into becoming pregnant so that they could rent accommodation or open a bank account for themselves or their family members. We surely cannot introduce legislation that places women at risk of such exploitation.
Before turning to the particular amendments, I shall address some of the questions that have been asked. The noble Baroness, Lady Smith, asked me about the health consultation. The Bill provides that certain expensive treatments could be charged for, even though persons have paid the surcharge—it is important to have flexibility in the legislation—but when the Act is initially implemented it is our clear policy intention that there will be no further charges for treatments where people have paid the surcharge. They will be treated as if they are permanent residents. The Bill’s provisions are therefore wider than the application of the legislation
The noble Baroness also asked me about the transitional arrangements. There are no transitional arrangements to the extent that anybody who is already here under existing immigration laws permitting them a period of stay greater than six months will not to have to pay the surcharge. The payment will be required only of people who are making a new application or new applicants. It should be noted that if somebody is extending their leave by making a fresh application the surcharge will become due. There is no question of trying to recover the surcharge from people who already have a right to be in this country for more than six months.
Baroness Smith of Basildon
I apologise for interrupting the Minister, and I am grateful for his response to my queries. I am still slightly confused on the issue of pregnant women. I think that he said that the Bill allows for such charges but there is no intention to make them. If I have that wrong, perhaps he could clarify it for me. The only reason it has been flagged up is that the public health consultation mentioned additional charges. I want to be absolutely clear that if a woman has paid the surcharge, there is no additional charge to be made. I may have misunderstood, but what he said seems slightly contradictory.
The other point is on transitional arrangements. If someone is already here legally, my question is about the practicality and workability of the measures. How will we be able to distinguish between someone who has paid the surcharge but is here illegally and someone who is here legally but has not paid the surcharge?
Lord Patel
If the Minister will allow me, before he answers the noble Baroness, can I make something clear? We keep confusing surcharge with levy. Let us talk about the levy that will be imposed on people coming here who are not visitors. Once that levy has been paid, it will allow them to access all health services. Is that quite clear?
Lord Taylor of Holbeach
Yes, that is exactly right. They will have the same access to health services as is available to a permanent resident. That is the whole purpose. It is administratively a tidy arrangement; it is straightforward and easy to police; and people will be paying it at the same time as they apply for their visa. Their visa application will show that they have those rights, so if anyone seeks to charge such a person, they will not be chargeable because they will have a clear right to free healthcare, just as the noble Lord and I would.
It is really important to emphasise that point, because the whole point of having the levy, the charge or whatever we call it, is to provide a contribution from people who stay here and may impose some cost on the health service but to avoid asking them for payments for services provided or to take out an insurance policy before they come here to cover any chance that there will be health costs. It will be an asset to the health service in the sense that it will provide money to support the health service. It also regularises the position of the individuals involved. I hope that that satisfies the noble Lord.
Lord Patel
It does, but I wonder whether this is new policy thinking, because much in the Bill, particularly in this part, implies that the Government want to be able to impose charges for other things.
Lord Taylor of Holbeach
I do not think so. I think that the Bill’s provisions are purely about health service charging for those who come here for a fixed term of six months or more and who are not here as visitors. It clearly differentiates between those who are here legally and with proper documentation and those who are illegal, so it will make it more difficult for those people who are here illegally to avoid the implication of their illegal presence here in the United Kingdom. We should remember that most people who are here illegally are overstayers; they are not people who have come in but people who should have gone home. That is one thrust behind the legislation.
Baroness Williams of Crosby (LD)
May I press the Minister just one step further, since this is quite a complex area? I think I am right that, at present, students count as being ordinarily resident as distinct from permanently resident. In future, because the ordinarily resident concept will broadly disappear, they will be regarded as permanent residents only if they put in the time to become, eventually, citizens in that sense. Many students, particularly those who are post-doctorate, continue to work in some area associated with what they are doing. For example, many post-docs work on research and are paid for it. If those students then pay taxes and national insurance on those earnings which they receive, but which are often well below what the market rate would be for their level of qualifications, am I right in thinking that they would not have access to free health treatment unless they had paid the surcharge at the moment when they got the visa?
Lord Taylor of Holbeach
They will have access currently, as the noble Baroness will understand. When they make an application to come here from now on, they will have to pay the health surcharge on top of the visa that they are currently applying for. I hope that I have made that clear. At the same time, it has been suggested from the Box that I ought to make it absolutely clear that the surcharge will be paid when a person applies for a visa and for leave to remain when they are in the UK and extending their leave. I think that was what I said, but the Box obviously thought that it is such an important point that everyone should understand that.
Lord Patel
My Lords, what the Minister said in response to my question is clearly recorded, so we can all read it. As I understood it, I thought he said that once the health surcharge—let us say it is £200—is paid, for the duration of their legitimate stay in this country all health services will be available to them.
Lord Taylor of Holbeach
It is a per annum charge, so if they are here for three years and are not a student it will be three times £200. But yes, that is exactly right.
Baroness Williams of Crosby
On this point, I am sorry that we are pursuing the Minister, but can I take this one step further? I was talking specifically about a post-doctoral graduate who might be earning some relatively small sum while he was a post-doctoral graduate. I take it that he would therefore not be exempt from the surcharge as well even though he would be paying both national insurance and taxation, if he was about the taxation threshold, and had paid the surcharge already. That is where the sense of some unfairness in the system arises rather strongly.
Lord Taylor of Holbeach
I suppose that at any boundary point, there are bound to be these sorts of situations occurring. The post-doctoral leave to remain would be in addition, perhaps, to a university degree. There would be an additional application, so indeed it would be allowable because they would not be permanently resident here in the UK. That is a correct analysis of the situation and the noble Baroness, Lady Williams, is absolutely right in pointing that out.
Lord Avebury
My Lords, I hesitate to add to the interruptions that the Minister has already suffered, but I think I can understand what the noble Lord, Lord Patel, was getting at. Clause 33(4) states:
“In specifying the amount of a charge under subsection (3)(b) the Secretary of State must … have regard to the range of health services that are likely to be available free of charge to persons who have been given immigration permission”.
That implies that not all health services will be available to that person, but the noble Lord has insisted that such persons will be treated on the same basis as a native of this country in accessing the health service. Why do we need subsection (4), which implies that there are other services which the health service provides that are not covered by the surcharge?
Lord Taylor of Holbeach
I thought that I had made that clear in answer to an earlier question, and I am just trying to find my notes on that matter. When the Bill is initially implemented, it is our clear policy intention that there will be no further charges for treatment. The provision in the Bill is there for this particular period, but we will clarify the position on implementation. The policy position is that there will be no further charge. That is not on the face of the Bill, as the noble Lord, Lord Patel, rightly points out, but I am giving him the policy position from the Dispatch Box. I hope that that reassures him and my noble friend on that point.
Baroness Tonge
Would the Minister be patient one more time? I thank him very much for giving way. Unless the granting of a visa is made dependent on paying the health surcharge, will poor migrants—let us assume that a lot of people wanting to come to this country are coming for a better life and are very strapped for cash—not waive the health charge, or whatever we like to call it, and assume that because they are healthy when they apply for their visa they will never need medical treatment? Is there not a danger that we are forcing people into a situation where they will not be able to receive any medical treatment at all because they will be too poor?
Lord Taylor of Holbeach
I have to say that we are not looking to put people in that situation. Indeed, one would hope—this is the reason for the provision—that if people are here for a period of time, they have got cover for their healthcare. That is the whole point of the charge in the first place. If people come as temporary visitors then that is a slightly different position, but they make that choice. They make the choice to come here, and they carry the responsibility to do so.
Perhaps I may turn to some of the amendments. It is good that we have had this chance to talk about the principles behind the charging and I hope that it has clarified the position to some degree. However, there are points here that I think I need to clear up. The first is that the restrictions to services set out in Part 3 are designed to protect our services from illegal immigrants—people who are remaining here outside the law. Many of these provisions will have no impact at all on pregnant women who are in the UK lawfully. The Government are committed to ensuring that the new restrictions and charges in Part 3 are appropriately targeted and do not impose a disproportionate burden on either service providers or migrants.
I should like to address some other points regarding Amendments 59, 60, 63, 64A and 65, which seek to exempt pregnant women from the health surcharge or the NHS treatment charges. I fear that there has been a misunderstanding about the purpose of the surcharge and the manner in which it will operate. As I say, the surcharge will be paid by legal, temporary migrants who come to the UK for more than six months. Our policy intention is that those who pay the surcharge, including pregnant women, will not be subject to most other NHS treatment charges. That will include both antenatal and postnatal care. They will be charged only for services that a UK resident might also be expected to pay for.
Amendment 60 also seeks to exempt children under the age of 18 from the surcharge. This would undermine the general principle that temporary migrants should contribute to the NHS, commensurate with their immigration status. Children are as likely to need NHS care as anyone else. It is therefore reasonable to expect parents—and it would be parents—to make this contribution on behalf of their child.
We have seen the headlines about health tourism. I am afraid that Amendments 63 and 65 would exacerbate the problem of maternity tourism. They would allow any pregnant woman to use the NHS free of charge. The NHS is not equipped to supply free maternity services for the rest of the world, and I do not think that that is an unreasonable thing for a government Minister to say.
Baroness Cumberlege
Amendment 63, which I tabled, proposes four new subsections. Proposed new subsection (1A) states:
“Notwithstanding subsection (1), any pregnant woman shall be treated as ordinarily resident”,
and proposed new subsection (1B) states:
“However, subsection (1A) shall not apply where there is evidence the woman has entered the UK for the purpose of obtaining healthcare”.
I think that is quite clear. I am saying that people who apply here simply for the purpose of obtaining healthcare should normally have to pay. Perhaps the Minister will clarify that. I am still very concerned about the three examples I gave. Will he address them? The first is a woman who came in with her husband and the relationship has broken down. Is she now exempt from these charges? The second example is a woman who is destitute and living on the streets. If she becomes pregnant as a result of a sexual assault, is she exempt? The third is a woman who is married to a British man and has submitted an immigration application to the Home Office who becomes pregnant and gives birth while the application is being assessed. Is she to be charged? It is not just maternity services; it is the other services being introduced in this Bill, such as prescriptions, dental care and A&E.
Lord Taylor of Holbeach
My noble friend is very prescient because I was just about to turn to Amendment 63. It is exceptionally difficult to prove that a migrant had a prior intention to use the NHS. Pregnant migrants would simply say that they fully intended to return home for the birth of their child. It would be difficult, if not impossible, for us to prove otherwise if they were a temporary migrant. This amendment would require GPs and hospital staff to act as immigration officers, and that is exactly what we are trying to avoid in setting this charge.
I have an answer here for my noble friend on victims of sexual assault. I have been speaking for 30 minutes, which is way beyond the conventions of the House, in answering these amendments. I am quite prepared to go on if noble Lords are prepared to do so. Other noble Lords are waiting to hear the Statement, and I have to crave their indulgence. If I skip any points, I will try to sweep them up by writing to all noble Lords who have spoken on this group of amendments, but there are an awful lot of points. I am literally but halfway through my speaking notes.
My noble friend asked about the operation of NHS charging regulations. Urgent treatment will always be provided no matter what the circumstances, and the Department of Health will still have the power to exempt treatments from charges. It is considering what exemptions for vulnerable groups are appropriate as part of its reform programme; there is no provision in the Bill.
My noble friend also asked whether women who have outstanding NHS debts will receive care. Women who pay the surcharge will not incur NHS debts. Where illegal immigrants or visitors incur debts, they will still receive treatment where it is immediately necessary or urgent. Their NHS debt for this treatment exceeding £1,000 will be taken into account by the Home Office when determining future immigration applications.
I reassure my noble friend Lady Tonge and the noble Baroness, Lady Finlay, that pregnant women in need of NHS care will receive it. Our intention is that surcharge payers will receive this care free of charge, at a fraction of the real cost of maternity services. Those who do not pay the surcharge, such as tourists and illegal migrants, who might otherwise be charged for maternity care, are also protected. Guidance to the NHS is explicit that, in order to protect the lives of both mother and unborn child, all maternity care, including routine antenatal care, must be provided to all women without delay caused by charging issues. I hope that I have made that clear in all the answers that I have given: the health of mother and child is paramount, regardless of the charging regime or the status of the mother.
Baroness Smith of Basildon
I am sorry to intervene on the noble Lord; I know that noble Lords are anxious to get on to the next debate. The answer the Minister gave me was not the answer to the question that I asked. I asked about those who have leave to remain in this country and are here legally—they could be UK citizens—but, having fled the domestic home where they have been subjected to violence, do not have the documents to show to a landlord and so cannot prove their status. How does the noble Lord intend for that matter to be dealt with, given the problems that it will cause to women fleeing domestic violence?
Lord Taylor of Holbeach
My Lords, I remember that the noble Baroness painted this scenario and I understood it well enough; I am sorry if I missed that point in picking up another. There are exceptions for refuge accommodation and local authority-provided housing. After all, a broad range of individuals are in this situation. Social services will be able to help them with long-term housing needs and asylum seekers will also be authorised to rent. If I have not satisfied the noble Baroness, I do not want to mislead her or the House by giving her an off-the-cuff response which is beyond my brief at the minute. I will write to her, and copy in everyone, on this matter.
I am looking through these notes, and see that I have satisfied a number of questions—such as those raised by the noble Lord, Lord Patel, on children—in the way in which I have answered the broader matters. However, I recognise, too, that I may not have covered all the points made by noble Lords, but I am very mindful of the time. If noble Lords will forgive me, I will ask the noble Earl, Lord Listowel, to withdraw his amendment. I thank all noble Lords who have contributed to the debate, which is by way of a warm-up, I suspect, for further adventures in these fields with the amendments that are yet to come.
The Earl of Listowel
My Lords, I thank the Minister for choosing to give the lengthy reply rather than the short one. This is clearly a matter of great concern to many of us, so I am most grateful to him for taking the time to answer our points as carefully as he could. I beg leave to withdraw the amendment.