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.
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.