Immigration Bill
Baroness Masham of Ilton Excerpts(10 years, 7 months ago)
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“Exemption of charging for primary medical services where charging is not cost-effective or poses a risk to public health
(1) Section 182 of the National Health Service Act 2006 (remission and payment of charges) is amended as follows.
(2) After subsection (1), insert—
“(2) Insofar as any regulations under section 175 provide for charges to be made for the provision of primary medical services, they shall include provision for the remission in full of any charge that falls below the minimum threshold of service cost.
(3) In subsection (2), the “minimum threshold of service cost” shall be the cost to the provider of primary medical services below which no charge is to be made for the provision of those services.
(4) Where regulations under section 175 provide for a charge to be made for the provision of primary medical services, the provider of those services may waive the charge where he or she considers that the cost of recovering the charge is not economical or where the consequences of charging may put the public health at risk.””
Baroness Masham of Ilton (CB)
My Lords, Amendment 52 is to do with public health protection. In Committee, the noble Baroness, Lady Cumberlege, spoke to this amendment, for which I was very grateful as unfortunately I had a long-standing commitment which I had to attend. The noble Baroness, like me, is passionate about health safety and knows that the Bill may cause danger to the health of the nation. Some people who have not paid the health levy may not seek help when they become ill because they fear being reported to the authorities and they may not have the money for tests and medication.
I am particularly concerned because, with the resistance to antibiotics and antivirals, diseases may be spread when people leave treatment too late. If they think they have to pay for medication, they will not go to primary healthcare for diagnosis. What will be the point?
As it is, it is very difficult to find some homeless people who need screening and I congratulate the organisation Find and Treat. I thank both Ministers for the recent meeting we had with the noble Lord, Lord Taylor of Holbeach, and the noble Earl, Lord Howe. It is important that departments work together over this complex matter with Public Health England. This amendment is to do with public health and cost-effectiveness.
I declare an interest as an officer of the APPG on Primary Care and Public Health and the groups on HIV and tuberculosis.
The purpose of the amendment is to provide an exemption from NHS charges where the cost of imposing and recovering a charge is not cost-effective or where the imposition of a charge constitutes a risk to public health. Doctors of the World supports this amendment, as do other health organisations.
In its response to last year’s consultation, the Royal College of General Practitioners made clear that it,
“opposes any change to the eligibility rules for migrants accessing GP services”.
Among the reasons given for its opposition were risks to public health and the imposition of new administrative burdens. Dr Mark Porter, the chair of the BMA council, has described the proposed charges as, “impractical, uneconomic and inefficient”. The Academy of Medical Royal Colleges emphasised in its response to the consultation that any proposals adopted,
“should not … create a bureaucratic process and burden that outweighs any tangible benefits”.
The amendment does not prevent charging but provides some flexibility within the proposed system to make it more cost-effective. The requirement to set a,
“minimum threshold of service cost”,
introduced in proposed new subsections (2) and (3) of Section 182 of the National Health Service Act 2006, achieves this. It requires the Secretary of State to stipulate a figure in regulations. If the cost of providing primary care falls below the stipulated figure, there is to be no charge. Similarly, if the provider of primary care considers that it will not be cost-effective to recover the charge, the provider may waive the charge. This would be achieved by the amendment in proposed new subsection (4) to Section 182 of the National Health Service Act 2006. Section 182 concerns exemptions from charges, including NHS charges to be made under Section 175, to which Clause 34(2) of the Bill refers. To this extent, the amendment responds to the concerns of the Royal College of General Practitioners, the BMA council and the Academy of Medical Royal Colleges. The Department of Health has acknowledged that,
“the administrative cost may outweigh the recoverable charges for frequently used but relatively inexpensive services”.
Lord Taylor of Holbeach
My Lords, I agree that this is a very useful opportunity to inform the House of where we are on this issue. The noble Baroness, Lady Masham, will understand that the provisions in the Bill are one thing and the wider provisions for implementing health service charging are another. We had a really useful meeting with my noble friend Lord Howe where a number of noble Lords present came to talk about this issue. I think noble Lords will agree he is very much focused on the full implications of any changes. I reassure the noble Earl, Lord Sandwich, that Médecins du Monde corresponds with me on a fairly regular basis so I know what its concerns are and unfortunately it was not at the meeting with the noble Earl, Lord Howe. If it had been I think it would have understood better the way in which the health service reforms were being taken forward. The other thing which it would certainly have picked up is that it is absolutely clear that treatment for infectious public health conditions is free to all and will remain so. We should just make that clear; I hope that it reassures my noble friend Lady Williams and the noble Baroness, Lady Masham.
As we discussed at length when we were talking about this issue, any exemptions from the NHS charging of short-term visitors and illegal migrants are not really a matter for the Home Office. This is not a provision that is being enacted in the Bill and is not a question on which the Home Office would make a decision. Exemptions are a matter for the Department of Health. I know that they are being considered very sensitively. Let us not forget that, within the devolved remit, while there is one United Kingdom for immigration purposes there are four national health services within the United Kingdom. It is not for me from this Dispatch Box to speak on their behalf. I have no wish to cause a constitutional crisis by inadvertently taking over responsibilities for which I have no responsibility.
My noble friend Lord Howe has agreed to meet again with noble Lords. I think that everybody felt that that was a helpful meeting. I want to keep everybody in the loop; I can act as a facilitator in this respect. When my noble friend’s department has developed more detailed proposals for reforming NHS overseas visitor charging arrangements—and it is that charging which is being looked at in particular, for people on short visits here—this will provide the appropriate time and context for discussions on the NHS charging arrangements for these groups.
Going back to the beginning, I confirm that treatment for infectious public health conditions is free for all and will remain so. I hope that that is a big reassurance. Given that reassurance, alongside our existing commitment that GP and nurse consultations will remain free to all and that that is not limited to the first consultation, I hope that the noble Baroness will indeed withdraw her amendment. I look forward to having further discussions with her and my noble friend Lord Howe in the future.
Baroness Masham of Ilton
My Lords, I thank the Minister and all who have supported the amendment. What is confusing is that Clauses 37 and 38 cover the new charges and restrictions of healthcare access in this Bill. Therefore, it is surely an immigration and health matter. Therefore, unless there is a combination working together on this complex matter, there will be confusion and people may fall through the net. I hope that I have helped to get the message across that public health and protection are vital, especially when dealing with vulnerable people. I beg leave to withdraw the amendment.
Immigration Bill
Baroness Masham of Ilton Excerpts(10 years, 8 months ago)
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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.
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.
Disabled People
Baroness Masham of Ilton Excerpts(13 years, 6 months ago)
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Baroness Masham of Ilton
My Lords, I congratulate my noble friend Lord Low on winning the ballot for this debate, which has shown how wide and varied are the needs of disabled people. Having had a spinal injury resulting in being paralysed from the chest down, I can assure your Lordships that people who are disabled will always face plenty of challenges and extra expenses. We have a Prime Minister who has experienced severe disability at first hand. I applaud him for the loving care that he and his wife gave their disabled child but some disabled people are not so lucky as to have such support. Many families break up under the strain and we must not forget the cruel treatment that Mrs Pilkington and her disabled daughter had to suffer at the hands of bullies, which ended in her suicide. We live in a complicated society and people with genuine disabilities need protecting.
I declare an interest as president of the Spinal Injuries Association, which has made a robust response to the recent government consultation on proposals to reform the disability living allowance, which will become the personal independent payment. The SIA is concerned by the introduction of a six-month qualifying period for PIPs. This will mean that newly disabled people, those most in need of support, are left without the appropriate funding to meet their needs.
The NHS reforms and the enormous upheaval might give an opportunity to look at some of the needs of disabled people when they have to be admitted to hospital. Many disabled people have to be admitted to general hospitals as there are not enough beds in special units such as spinal units. The patients then face the lack of vital equipment such as monkey poles, turning beds and pressure mattresses to prevent pressure sores, help with paralysed bowels, enough pillows and incontinence products—to mention just a few of the many needs. They also need staff who know what they are doing. Disability should be part of a nurse’s training.
I am a past president of the Chartered Society of Physiotherapy and know personally the benefits of physiotherapy for disabled people. Physiotherapists are one of the health professions who have a critical role in improving people’s physical capabilities, whether that is in getting someone back to work or school, or just to improve their quality of life. At the moment, physiotherapists are worried about the loss of specialist clinical posts in the NHS, the widespread freezing of physiotherapy vacancies and the rationing of treatment sessions that they can now provide due to the efficiency savings required of the NHS. The Chartered Society of Physiotherapy says that this is an increasing problem and is concerned about the impact on people with disabilities. The right health and social care can greatly improve the quality of life for people with Parkinson’s, for example. This includes access to a specialist, multidisciplinary team of Parkinson’s special nurses, specialist physiotherapists and speech and language therapists—as recommended in the NICE guidelines on Parkinson’s—and appropriate social care, including support for carers.
The wheelchair service needs a complete overhaul. It is totally inadequate. Who will be responsible for this? I am glad that the noble Baroness, Lady Thomas of Winchester, mentioned that.
With the reforms to the NHS, the Government have suggested that GP practice boundaries should be removed. Could this be a threat to continuity of care? I am a keen supporter of the saying, “No decision about me without me”. Disabled people who are vulnerable and less mobile need both helpful GPs who are interested in their special needs, medication and ongoing care, and the support of expert specialists. Some disabilities are extremely complicated. If patients find that their GP is not helpful, then they are better moving to another practice. This can be very difficult in some rural areas, especially for disabled people. The consortia should be made up of different health professionals who understand the different needs of complicated patients and patient representation. The responsibility for wide-ranging disability needs experts. GPs are generalists and need to work together in union for the good of patients. There should always be good communication between specialists, GPs and patients.
Patient safety should be the priority at all times, not just financial interests, and there should always be a good standard of care. Disabled patients can be the most at risk. Many patients with long-term conditions often need to get their specialist treatment a long way from home, as the specialist units are few and far between. These can be life-savers but disabled people need to keep in touch with their homes. Could the cost of telephoning from hospital be brought down? It is very expensive.
While there is a pause in the NHS reforms, I hope satisfactory solutions will be found in the best interests of patients. There are always the worried well but now, with so many changes suggested, there are genuinely worried disabled patients who find the cost of disability and cutbacks extremely draining on their systems. We have heard little about how Health Watch will work and if it will be able to support patients when they have a genuine complaint. When disabled people have problems, these can involve legal matters and knowledge of the law is necessary. Disability covers so many different aspects of life.
I am a member of the Patients Association, which has a helpline. The most common complaints relate to accessing healthcare. People feel that hospital transport services are often inadequate and blue-badge holders often find provision of disabled spaces is low and taken up by non-badge holders. Within hospitals, the most common cause of complaint is the lack of help for disabled people going to the lavatory. I can bear this out. When I was visiting Peterborough hospital on an occasion when my husband was admitted as an emergency, a man implored my helper to take him to the lavatory. He could only hop on one leg. Another man asked if she would give him a shave. This was in the afternoon. To my amazement, there were two care assistants chatting at the nurses’ station. Perhaps that is why we hear about nurses who are too posh to wash. Also there is the unwillingness of nurses to feed patients who are too disabled to feed themselves; the food is left at the bedside, untouched. That is another common complaint.
Patients often complain that medical professionals treat them differently because they are disabled. It is time that compassion was put back into nursing. Up and down the country one hears cries of “Bring back the matron”—not just the so-called modern matrons, who do not seem to have made a difference, but people who will take full responsibility for nursing care and nurses. Helping disabled people takes extra time and time can cost money, but surely there is more to life than just economics.