National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017

Lord Hunt of Kings Heath Excerpts

Thursday 16th November 2017 Lords Chamber

Moved by

[Lord Hunt of Kings Heath]

That this House regrets that the National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017 do not clarify how upfront charging can work without increasing barriers to healthcare for vulnerable groups, how they will not breach equality legislation through the potential use of racial profiling as a means to identify chargeable patients, and how the extension of charging to community services will not lead to patients being prevented from accessing preventative care programmes; and further regrets that they have been introduced without sufficient assessment of the effectiveness and value for money of the bureaucratic process proposed (SI 2017/756).

[Lord Hunt of Kings Heath (Lab)]

My Lords, I am moving this Motion because I believe the regulations on charges for overseas visitors do not clarify how up-front charging can work without increasing barriers to healthcare for very vulnerable groups. They do not explain how they will not breach equality legislation through the potential use of racial profiling as a means of identifying chargeable patients. The regulations do not show how the extension of charging to community services will not lead to patients being prevented from accessing preventive care programmes. I also believe that it is a matter for further regret that these regulations have been introduced without sufficient checks of the effectiveness and value for money of the very bureaucratic process proposed.

Let me say at once that, on the face of it, charging overseas visitors to use our hard-pressed NHS is entirely reasonable. But the Government’s latest plans to extend charges to community services will raise very little money, place a huge bureaucratic burden on the NHS and deny healthcare to very vulnerable people. The UK already charges some overseas visitors for most hospital care after treatment. Patients who are not eligible for free care include short-term visitors, undocumented migrants and some asylum seekers whose claims have been refused. There are already processes in place for hospitals to identify and bill such patients. We understand that in addition to these regulations, the Government are considering extending charging to A&E and GP services.

Under the regulations that came into force last month, all community services receiving NHS funding, including charities and social enterprises, are now legally required to check every patient’s paperwork, including passports and proof of address, before they receive a service to see whether they should pay for their care. Charges are up front, with non-urgent care refused. As a person will need to provide paperwork and/or a passport to prove eligibility, there is a distinct possibility that people who are entitled to free care on the NHS will be denied treatment because they do not have it at hand. Particularly vulnerable groups here include the elderly, asylum seekers, homeless people and mentally ill people. Moreover, if patients continually have to provide details every time they need healthcare, this risks them waiting longer, with an inevitable increase in bureaucracy.

Asylum Matters, in conjunction with a number of other organisations, has commented in response to the Minister, who has written both to Members of this House and to MPs in the House of Commons to allay fears about how patient ID checks will be carried out. He says that the changes do not require a patient to provide a means of identification to qualify for free care. He says that, while that may be helpful in demonstrating eligibility, other information will be used by trained NHS staff to ensure that the residency status of a patient is identified. He says that the regulations simply require that a relevant body must make such inquiries that it is satisfied are reasonable in the circumstance to determine whether charges should be made. The problem is that those protections are not built into the regulations. They may be in the guidance but guidance can be changed at any point, and they cannot be enforced if NHS organisations choose to insist on further proof of a patient’s ID.

I have been written to by many people, and I would like to refer to a very important paper sent to me by Natalie Bloomer, in which she refers to the father of a newborn baby who recently received a letter from his local hospital demanding to know whether his eight day-old child was entitled to free healthcare. The parents wondered if they had received the letter due to the mother’s foreign-sounding maiden name. When the father went back to the hospital, it quickly told the family to disregard the letter. For me, this highlights the whole problem of this wretched and miserable policy. It is quite clear to me that, apart from the dreadful impression and reputation it gives of our country, many people who legitimately live here and have every right to NHS treatment are going to be challenged by the NHS. I find this absolutely despicable.

I gather that the Secretary of State has claimed that charging regulations simply bring us into line with our European neighbours. Of course, this is complete nonsense. The work done by Doctors of the World, which I have seen, has been researched comprehensively, and the fact is that many European countries, particularly the ones we tend to compare ourselves with, actually provide a more comprehensive package of free healthcare—for instance, to undocumented migrants.

I receive many briefings and letters from reputable organisations. This regret Motion has been backed by many trusted and well-respected bodies, including the BMA, the Royal College of Midwives, Doctors of the World UK, the National AIDS Trust, Asylum Matters and Freedom from Torture. Many of them represent groups which will be intimately affected by the regulation introducing and extending overseas charges.

They are not the only ones to oppose this new policy. An open letter addressed to the Secretary of State, published by 193 organisations and 880 individuals, has called for the regulations to be dropped as soon as possible. Among the signatories were 300 doctors, 50 nurses, the former NHS chief executive Sir David Nicholson, the Royal College of Paediatrics and Child Health, and Amnesty International. Not only were they all agreed that the introduction and extension of charges will place a greater burden on the NHS, but this is the kind of thing that the Conservative Government pledged to cut down—the wretched bureaucracy involved and the time that will be spent by staff trying to make these charges work. The Royal College of General Practitioners has flagged up the possibility the new system could end up overstretching already strained family doctors at medical centres. The Catholic Bishops’ Conference, in its letter, spoke of the catastrophic consequences of the new regulations and asked for them to be suspended.

Not only is this a ludicrous action by the Government, it will have no impact whatever on the finances of the NHS. The estimate is that it will bring a £200,000 saving—how ridiculous. The point I want to make in the debate tonight is that these rules are now already law. The Catholic Bishops’ Conference has asked for the regulations to be suspended, and I hope the Minister can announce that he is going to do that, but at the least there should be an early independent review of how the new charges are operating. Until then, there can be no question of extending charges to yet more services. I beg to move.

[Baroness Hamwee (LD)]

My Lords, I thank the organisations that have briefed us. Sending a joint briefing was particularly helpful, not because it reduces the paper but because it increases the force of the content. It came from Asylum Matters, Doctors of the World UK, NAT and Freedom from Torture. We have had briefings from others too. I also thank the noble Lord, Lord Hunt. Like him, I understand that some charging of visitors is entirely reasonable, but—and it is a very big but—the noble Lord has raised some very pointed questions wrapped up in the text of his Motion, and I hope that the Minister will be able to respond to those point by point.

This is not a new problem for some groups but it is now worse. During the passage of the Immigration Bill, now the Immigration Act 2014, the points were put forcefully—especially, I remember, by those concerned with maternal health and by doctors who were working with a wide range of immigrants. I remember hearing from Doctors of the World UK that, before the regulations which followed that Act came into force, there were queues round the block at its clinic of people who were anxious about what their position would be afterwards.

The charging then was presented as an innocuous extension of the system, and really very beneficial. There was a lot of talk about health tourism blocking access for those of us who are not tourists. I began to think that the world must be full of people who had had their pregnancy confirmed and immediately booked a flight for the due date minus however many weeks the chosen airline applied as the cut-off for carrying pregnant women. At that time, it became clear that many hospitals found the charging system then in force so burdensome that it had simply defeated them, and there was a good deal of criticism of those that were defeated, I recall. This time around, again there has been considerable protest from people who have seen at first hand the effect of what the pre-23 October regulations require.

When I looked for the government impact assessment on the regulations, I found an evaluation by Ipsos MORI of the overseas visitor and migrant NHS cost recovery programme, published in January this year but apparently started in 2014. The paragraph on the costs and benefits of implementation made startling reading—which I found difficult because I printed it off in such a small font. It made me doubt whether there really was benefit to the implementation. What continued valuation will there be? This is another way of asking the question that the noble Lord, Lord Hunt, asked: will the Government consult before extending the charges into other health services, including A&E and GP services? The letter that the Secretary of State wrote in response to the open letter seems to say these things are so because they are so. I am sure that there cannot be as relaxed an attitude as that seems to suggest.

--- Later in debate ---

[Lord O’Shaughnessy]

For clarity, they are not covered under the exemptions.

The second change the amendments make is to the requirement that any care not deemed immediately necessary or urgent by a clinician is paid for up front. The published guidance, again, for nearly 30 years, has recommended this. This practice ensures that a chargeable patient can make an informed choice about their care and therefore does not unwittingly incur debts when they could instead, for example, choose to wait for treatment until they have travelled home. Given that our NHS is facing unprecedented levels of demand, I hope noble Lords will agree that mandating this position is a sensible approach and that it will help make sure that all users of the NHS make an equitable contribution to ensure its continued success and viability.

The noble Lord, Lord Hunt, has asked whether this practice will not create barriers between vulnerable patients and treatment and result in racial profiling as the front line seeks to determine eligibility for free care. I have already drawn noble Lords’ attention to the exemptions in place and the fact that all GP and A&E services remain free for all. I am also clear that immediately necessary or urgent treatment—such as all maternity services—will never be withheld, regardless of the patient’s ability or desire to identify themselves or pay. To reassure the noble Baroness, Lady Taylor, and other noble Lords, it is for clinicians, and no one else, to determine whether a treatment is immediately necessary or urgent.

On whether patients may face discrimination, this is always unacceptable and not compliant with anti-discrimination legislation. As my noble friend Lord Leigh pointed out, our guidance is clear that simple, short questions should be asked by trained staff of all patients whose records do not already indicate residency status to assist in identifying those not eligible for free care. That information can then be captured in the patient record for the future.

To support the implementation of these regulations, we have developed with front-line staff a “cost recovery toolbox” containing extensive guidance and template letters to patients and clinicians, as well as patient and staff-facing leaflets and posters and a web-based forum for peer support. As my noble friend Lady Redfern pointed out, working with NHS England and NHS Improvement, the department has published operational guidance to support the introduction of the regulations. This includes an average price list to provide consistency in up-front charging. The department has recruited a senior, experienced cost recovery team of NHS professionals who have led improvement visits to over 20 NHS trusts over the last six months. Action plans are in place for each trust and the team will support improvement and the sharing of best practice across the wider NHS.

I would like to end on an issue which has been raised by many noble Lords in this debate: the assessment carried out before we introduced these changes. As I have explained, up-front charging did not represent a change in policy, but instead has existed for many years before the consultation on other amendments. Over the course of the consultation and decision-making process, the Government carefully considered the impact the charges may have and published a full impact assessment alongside the regulations. This concluded that the package of changes would identify up to £40 million a year for the NHS. This is additional income and takes into account any administrative costs associated with the changes. I will also place in the Library copies of the equality assessments carried out by my department to inform the regulations, so that Members of the House will be able to review how the impact on vulnerable and protected groups was very carefully considered prior to the introduction of these changes.

All noble Lords have asked about the implementation of these changes and it is right, of course, that we proceed cautiously and sensibly and that we review how we are doing. So I am very aware of the need to keep the impact of these regulations under careful review in order to make sure they are implemented as planned and with no unintended consequences. My department will therefore undertake a full, formal review of how these amendment regulations are implemented, and monitor delivery closely, particularly where healthcare is provided to the most vulnerable. If further action is needed I will commit to update the House accordingly.

I hope I have been able to reassure all Members of this House about the long-standing principles that underpin our approach to cost recovery, the care that has been taken to protect vulnerable groups, and the reflective approach we will take during the implementation of these policy changes. I believe that they provide an equitable and reasonable step forward in making sure that all the NHS’s users, wherever they come from, make a fair contribution to the sustainability of the NHS, which is what British citizens expect. On that basis, I ask the noble Lord, Lord Hunt, to withdraw his Motion.

[Lord Hunt of Kings Heath]

My Lords, I am very grateful to all noble Lords who have taken part in this debate. The fact we spent nearly an hour on it as last business on a Thursday is testimony to the importance of the matter, which is why I welcome so many noble Lords having stayed to take part. I will not push this to a vote, and I will withdraw the Motion, but I do think it is an opportunity to raise some very important points with the Government.

First, the noble Baroness, Lady Hamwee, made some very important points about the analysis of the impact assessment, the doubtful financial benefits set against the bureaucratic costs, and the impact this may well have on some of the most vulnerable people—the very people who, not just from their point of view but the public health point of view, need to access these services.

Secondly, from the evidence that I have received—and I have received many such examples—there is a real concern that people who are legitimately entitled to NHS services may get turned away. The noble Baroness, Lady Hollins, rightly asked what the safeguards were to prevent this.

I think it right that we talk about racial profiling because again there is some evidence that, in spite of what the Minister said and what is promised in guidance, this is taking place in some parts of the country. The NHS has many organisations—we have a lot of community organisations—but it turns out that staff who are given such responsibility may not be aware of the importance of this issue and its sensitivity. The obvious case here is British people with foreign-sounding names being challenged in a way which I think is inappropriate.

The Minister did not respond to the point from the noble Baroness, Lady Hamwee, about the Home Office requiring medical records. I do not know whether he will be prepared to respond to her in writing; I understand that the question goes much wider than his brief today, but I am concerned about the ethics of the Home Office requiring people to open their medical records.

The noble Baroness, Lady Hollins, was of course right to point out the barrier to people with mental health and other disabilities. This is not just about who is eligible: having to produce evidence to legitimise a right to treatment could prove difficult for vulnerable people who find everyday living hard and challenging.

Like my noble friend Lady Taylor, I say to the Minister—the noble Baroness, Lady Redfern, and the noble Lord, Lord Leigh, both spoke about this—that I have no problem with the principle of cost recovery. I accept that it is right that the NHS seek to recover costs from the people who are not eligible for NHS treatment. My problem, particularly with these regulations, is that I have a feeling they will be counterproductive and I doubt they will raise very much in the way of resources. My noble friend also teased out the point about the position of failed asylum seekers, who seem to be particularly vulnerable. I welcome what the Minister said about unintended consequences; that is a very important point.

Operational guidance, which the Minister referred to, is one thing. I would have preferred to see some of the points he has made and reassurances he has given in the regulations, rather than operational guidance. I also noted with great interest what he had to say about accident and emergency and GP services. From the confidence with which he said it, can I take it that the Government intend that they will remain free for all in future? Perhaps I can ask him quite what he meant by that, because in the briefings that I have had people have emphasised that it is the Government’s intention to extend the charges to accident and emergency services and GP services.

[Lord O’Shaughnessy]

We are talking about the regulations that we are implementing, and they do not introduce that. That is the point I was making.

[Lord Hunt of Kings Heath]

Noble Lords will interpret that response in the way they wish to. That is a bit disappointing.

The Minister has promised a review. I very much welcome that. He said it would be a full, formal review; let us hope it will also be an independent one. Asylum Matters has reminded me, in the most efficient way that that organisation works, that of course in 2016, a review was promised. I hope this time, we will actually get such a formal review.

Having said that, this has been an important debate. A lot of people are looking with great interest at what your Lordships have discussed tonight. We knew we were not going to be able to stop these regulations but I hope we have expressed those legitimate concerns. I am grateful to noble Lords for taking part and beg leave to withdraw the Motion.

Motion withdrawn.