The Parliamentary Under-Secretary of State, Home Office (Lord Taylor of Holbeach) (Con)
My Lords, this has been a very reasoned debate and I am pleased that we have had a chance to return to it. It has taken us slightly further along the track than the legislation takes us, but that is a feature of where we are. We have an Immigration Bill, a Home Office measure, that is designed to provide for a surcharge, which in turn is to provide free healthcare for those covered by the surcharge, and we have the health service itself, under the Department of Health, looking at ways in which it can more effectively recover sums that are due, under current legislation, from visitors—and, for that matter, illegal migrants and the like—to see how that can fit in with all the other considerations; public health has been mentioned, as well as the vulnerability of some of the patients who present themselves who may have become victims through no fault of their own and need proper medical attention. Those two things are going on at the same time. I suspect that at bottom that is why we are finding it a bit difficult to discuss this issue.
If I may, I will turn to the Bill itself to start with, as that is the most important thing. I am aware that I speak for the Government and I cannot say, “Well, this is my dear noble friend Lord Howe’s responsibility”, so I will do my best to integrate into one proposal both the Bill and the health service reforms. I reassure noble Lords that there is nothing in the Bill that will impact on the current arrangement for migrants in any of the areas covered by these amendments that have been debated this evening. Our intention is that the payment of the surcharge, which takes place when people make an immigration application, will entitle migrants to free access to the NHS in the same way as a permanent resident. This will include treatment for injuries sustained as a result of domestic violence, which the noble Baroness, Lady Meacher, mentioned, or female genital mutilation, which was mentioned by the noble Baronesses, Lady Meacher and Lady Finlay. It will also include mental health, to reassure my noble friend Lady Barker, and maternity services, as we discussed when we were debating previous amendments. We have also committed, as the noble Baroness, Lady Smith, said, to exempting victims of human trafficking. I can say to the noble Baroness, Lady Finlay, that there is no charge for anyone in detention accessing NHS healthcare.
Secondly—this is the second element of the debate—as my noble friend Lord Howe set out in his recent letter to noble Lords, the Bill does not make any changes to the way in which short-term visitors and, for that matter, illegal migrants access medical care. Any NHS charging exemptions for health purposes for these groups are a matter for the Department of Health and, within their devolved remit, the devolved Administrations. Within the framework of government, they are not the responsibility of the Home Office.
The noble Baroness, Lady Meacher, asked me how we will ensure that NHS staff can effectively identify potential victims of trafficking. The Department of Health already identifies patients who are victims or potential victims of human trafficking in order to waive treatment charges. We will work closely with the Department of Health on this matter in order to ensure that proper guidance and training are provided to NHS staff. I am not convinced that the amendments proposed by the noble Baroness are necessary.
I was asked why the national referral mechanism was not put on a statutory footing. It was set up to ensure that victims of human trafficking are identified and given the support they need. We want to make sure that the NRM is working as effectively and supportively as possible, and healthcare is part of that mechanism. That is why the National Health Service announced a review of the NRM on 3 December. It will commence shortly, and we await it.
The Department of Health has already confirmed that it will be exempting certain treatments from charging, including GP and nurse consultations, specified infectious diseases—we have talked about HIV and tuberculosis—and sexually transmitted infections. This will ensure that everyone has unrestricted access to prompt diagnosis and intervention and that public health is safeguarded.
The Department of Health has, however, signalled an intention to introduce overseas visitor charges for some primary care services, including A&E, as part of its extensive reform of NHS charging in England. It is carrying out detailed analysis to inform decisions in this area. I am confident that cost-effectiveness—noble Lords mentioned some of the consequences of poor primary care leading to complications that can be very expensive as a consequence—public health and the moral case for protecting vulnerable groups will remain key factors in this consideration. I can reassure noble Lords that any agreed changes will be put to Parliament in the form of revised NHS charging regulations. That is not an unusual situation. We are talking about a consultation. This aspect of health service reform is not appropriate in an Immigration Bill because it is not about immigration but the practice of charging within the health service.
Without getting involved in the argument as to whether that is the right or wrong thing to be doing, as we know, we have all been fortunate to grow up in a world in which, for most of us, all healthcare—well, not all healthcare; not dental care and things like that—has been free at the point of use. That is a remarkable privilege, but it is an expense and one has to argue whether the resources are properly justified if they are extended to visitors, for example, or illegal migrants. That is not an unreasonable position to take.
Baroness Meacher
I am sorry to interrupt the Minister. He understandably said that this was a matter for the Department of Health and therefore not really appropriate for discussion here. Can he assure the Committee that we will therefore have another opportunity to influence the design of these regulations, which will indeed determine whether people suffering with FGM, domestic violence and so forth will be excluded from health charges or not? That is a matter of great concern to many of us. If we cannot discuss it here, will there be another opportunity?
Lord Taylor of Holbeach
That is why I am going to try to address some of these matters. It is right to seek to do so, allowing for the limitations of my knowledge in this area, which I hope that noble Lords will understand.
This House has a good reputation for debating these sorts of things not, if I may say so, through the statutory instrument process so much as generally. I am absolutely certain that my noble friend Lord Howe would be quite prepared to come at a suitable point during the consultation to discuss the basis of changes that would be made. I am sure that I am not losing a friend for life by committing him to do just that.
As if to show that I need to brush up a little bit, apparently I may not have said, through mis-speaking or a slip of the tongue, that the Home Secretary announced the review of the NRM. I thought that I had implied that, but if I had not, I should have done so. Let us hope that I do not fall out with another friend for not crediting the Home Secretary.
The noble Baroness, Lady Meacher, asked about training for the enforcement of new NHS rules, and also about the Modern Slavery Bill which, as noble Lords know, is in pre-legislative scrutiny. The Department of Health will publish its implementation plan on the health service rules during the course of this year. The Modern Slavery Bill will be a fourth Session measure. I must not anticipate the Queen’s Speech, but the fact that that Bill is going through pre-legislative scrutiny rather suggests that it will be in the fourth Session legislation.
The noble Baroness, Lady Finlay, asked about a victim of FGM who has infected wounds. Under the NHS charging regulations and policy, immediate necessary treatment is not held up because of charging. I think that the noble Baroness has enough experience of how the health service operates charging principles, and I do not think that that is likely to change. GP care is not charged for, as I have said. The Department of Health is reviewing provisions for vulnerable individuals under these NHS regulations.
The noble Baroness asked why we were planning to charge migrants for accident and emergency services. Surcharge payers will obviously not have to pay for A&E services. The Department of Health has indicated that there is a good case for introducing overseas visitor charges for A&E, for those short-term visitors and illegal migrants who do not pay the surcharge. It is giving this detailed consideration, but will not make any changes unless it is confident that the new systems will work well without compromising rapid access to emergency care for those in immediate or urgent need, which will never be withheld or delayed pending payment. However, as I said, that is not a matter for the Bill. It is part of the review into regulations which is going on at the moment.
My noble friend Lady Cumberlege asked whether those exempted from the charges will be exempted from NHS charges. Our policy intention is that those who are exempt from the surcharge will also be exempt from subsequent National Health Service charging for health services under NHS regulations. However, obviously they will be liable for dentistry; as I mentioned before, at the moment that is not free other than in exceptional cases.
Under the Bill it is possible for surcharge payers to be charged for certain expensive discretionary treatments —I think we have discussed that already. However, we have made it clear that we intend that no such additional charges will apply when the surcharge is introduced. The Department of Health has made it clear that it would consider those in the future only in the event of any exceptional and compelling specific justification for health purposes, and, as I have already said, any changes would need to be put before Parliament.
My noble friend welcomed the exemptions, but those refused asylum will face charges, as will most victims of trafficking who are not recognised through the national referral mechanism. I emphasise to my noble friend that refused asylum seekers will not pay a surcharge. Health charging for refused asylum seekers is a matter for the Department of Health and the devolved health administrations within its remit. We have already confirmed that trafficking victims will not have to pay the surcharge.
The NRM is the only process by which an individual can be formally identified as a victim of trafficking and matched with appropriate support. Someone who has not been identified as a victim through the NRM and who is an illegal migrant or visitor would not be covered by the exemption for NHS charging under the existing regime. However, the NHS can write off NHS debts if individuals are subsequently identified as victims of trafficking, so there is a retrospective exemption in that regard.
The Department of Health has committed to give further thought to strengthening exemptions in the current NHS charging regulations for vulnerable groups, including victims of trafficking. We want to make sure that the NRM works effectively, which is why the Home Secretary has commissioned the review.
My noble friend asked whether those who come on a visa, pay the levy—or the surcharge, as it is properly called—and are later refused an extension will still get free NHS treatment while waiting for an administrative review decision, and asked about a period for which the paid levy has expired. This is about people and their leave to remain. Those individuals will continue to receive free NHS treatment as part of the conditions of their extant leave. Where individuals had leave, alongside which they paid the surcharge when they applied for an extension and applied for an administrative review within the specified time limit for doing so, their leave will be extended on the same conditions under Section 3C of the Immigration Act 1971 until their administrative review is decided.
My noble friend asked what would happen if their review is refused and they bring a human rights appeal. Once an administrative review is refused a migrant will be liable for NHS overseas visitor charging unless they fall under one of the exemptions set out in NHS charging regulations. That will be commensurate with their immigration status.
A number of noble Lords were concerned about GP consultations being free—I think that that is widely understood—but what about treatment? We intend for surcharge payers to receive most treatment free, as would any other UK citizen or person with indefinite leave to remain. We have made that clear in all the responses that I have given. They will be charged only for services for which permanent residents are also charged. As part of its work to reform the charging regime in England, the Department of Health has signalled an intent to extend charging for short-term visitors and illegal migrants to some primary care services, excluding GP consultations. It is carrying out a detailed analysis to inform decisions in this area, and any agreed changes will be put to Parliament.
I was asked by my noble friend Lady Cumberlege to give an assurance that the Home Office would not be permitted to use access to healthcare as a means for it to identify and take action against those subject to immigration controls. Healthcare staff are not routinely required to inform the Home Office on issues to do with individuals’ immigration status, and there is no plan to change this. However, there are circumstances where it is appropriate for the NHS to pass information to the Home Office, such as for enforcing the NHS debtors rule, which is a current rule under which migrants who have run up an unpaid debt of £1,000 or more are not given permission to enter the UK while the debt remains unpaid.
Finally, I hope that I have answered the questions posed by my noble friend Lady Barker on mental health and such matters. She made a valuable contribution to the debate.
I turn to the challenges presented by the noble Baroness, Lady Smith, who asked, “What is success?” Success might be the £2 billion surcharge income for the NHS, which is a large sum of money even in a health service budget running to several hundred thousand million pounds. An additional £500 million will be recovered in treatment charges each year through better administration, plus the surcharge, and vulnerable groups will be protected and treated. Part of the consideration of the NHS review and the provisions of the Bill are to ensure that vulnerable groups are protected. There is no adverse impact on public health, and there is a fairer set of rules and arrangements, which command public support. Those are the basic challenges that face us in seeking to reform charging within the health service.
I reiterate that the introduction of the surcharge in the Bill will give those who are obliged to pay it—and they are obliged to pay it—the peace of mind that they will receive comprehensive NHS treatment when needed. But charging for short-term visitors and illegal migrants remains the responsibility of the Department of Health, and it is not dealt with in the context of this Bill.
Baroness Barker
My Lords, I thank the Minister. I know that health is not his subject, but he has given an excellent response to those of us who speak fluent NHS and know all the language. I thank him for the detail of his response, but I ask him to write to me on two points. First, on my point about charging for diagnostic tests, I understand the point about people paying the levy having to pay for the same things as people who are resident and about the exemptions for some categories of people and some conditions, such as infectious diseases. But there are some conditions—for example, diabetes—where you have to have a diagnostic test. It is important that people know that they are diabetic and that healthcare workers know that those people are diabetic, because if it goes untreated there may be further consequences.
Secondly, I seek clarification on the important matter raised by my noble friend Lady Hamwee on whether initial consultations with GPs would be free and subsequent consultations would be charged for or whether all consultations with a GP practice’s staff would be free. I do not want to detain the Committee now but if the Minister could answer those two questions in writing, it would go a considerable way towards allaying anxieties in that regard.
Lord Taylor of Holbeach
I give that commitment. I will, of course, write on that. I will also go through the debate as other questions may have not have been answered, for which I apologise. The noble Baroness, Lady Finlay, nods, so I clearly forgot to answer one of hers. However, I will go through the debate and answer all the questions as best I can. Indeed, my officials will talk to officials at the Department of Health as some of these matters are the responsibility of that department, as we have already discussed. I thank the noble Baroness, Lady Barker, for her kind words.
Baroness Meacher
My Lords, I thank the Minister very much for his thoughtful response. He was able to give us some reassurance on some points. I think that there are still a lot of gaps, but I am sure that the Minister will respond to some of the points in writing. I am very grateful to him for his kind offer in regard to his colleague, the noble Earl, Lord Howe, meeting us. I assume I am right in saying that the Minister’s office will be in touch with the office of the noble Earl, Lord Howe, to set up such a meeting because I think that it is only in that forum that we can achieve clarity about some of the most important and concerning issues to do with health charges and these vulnerable groups. As the noble Baroness, Lady Smith, said, we are talking about the victims of criminal offences.
There is much to thank the Minister for, but we will have to read the debate carefully and think about Report. With that, I beg leave to withdraw the amendment.