Immigration Bill

Baroness Tonge Excerpts

Monday 10th March 2014 Lords Chamber

I also look forward to what the Minister has to say in response. I hope that he can genuinely reassure us this time, because I was not reassured by his response when these issues were raised in at Second Reading.

[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.

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[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?

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[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.