NHS (Foreign Nationals)

Anne Milton Excerpts

Tuesday 22nd May 2012 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (Anne Milton)]

It is a pleasure to serve under your chairmanship this morning, Mr Streeter. I thank my hon. Friend the Member for Kingswood (Chris Skidmore) for securing the debate, which has provided a useful opportunity for hon. Members from all parties to come together and share their views. I express some disappointment at the fact that the shadow Minister, the hon. Member for Copeland (Mr Reed), was somewhat party political, but I commend the hon. Member for Ealing, Southall (Mr Sharma) for his generous comments. It is important to have that on the record: we all want clarity and fairness in the system.

I have met my hon. Friend the Member for Kingswood before to discuss the matter and, again, I commend his efforts in raising the subject, which has provided an opportunity to put some things on the record. Access to NHS care is very poorly understood—indeed, that is also the case for Members of Parliament. This is about foreign nationals using and potentially abusing the NHS. Like the health system of any country, the NHS provides for foreign nationals. Millions of people come to this country every year for various purposes and stay for different periods of time. Some become ill or have accidents, and have immediate health care needs that need to be met. We have a duty to treat them, just as other countries have a duty to treat British citizens who become ill abroad. I assure the shadow Minister that there is no question of anybody wanting to undermine that duty—nobody has raised that in the debate, it is not being discussed either and that will remain the case. However, we have a duty to taxpayers who pay for the system.

Questions were raised about who should be charged. To clarify the situation again regarding ordinary residence—settled, lawful residency in the UK—access to the NHS is not based on nationality, the payment of taxes or national insurance contributions. I accept that that is not widely understood. The service is paid for by taxpayers, so they have an interest in who has access to it. We exempt some categories of visitor from charges, such as those working or studying and those visiting from countries with which we have bilateral health care agreements. A few services are free to all—my hon. Friend the Member for Kingswood may have mentioned them—such as treatment in an A and E department, which I have mentioned, and treatment for certain infectious diseases, as there are wider public health reasons for ensuring that people receive prompt treatment.

Under the legislation, charges can only be made for hospital treatment. Charging is not in place for registering with or seeing a GP, although prescriptions are subject to the usual charges. GP registration or the holding of an NHS number does not trigger free hospital treatment. The hospital to which a non-resident has been referred should check separately for eligibility, but I know that that does not happen as it should. Current legislation allows only for charging overseas visitors for NHS hospital treatment. There are therefore no rules of entitlement governing overseas visitors’ access to GP services, and visitors are able to register.

GPs are self-employed and are contracted to provide primary medical services for the NHS. Under the terms of their contract, GPs have a measure of discretion in accepting patients on their list, but they can only turn down an applicant on reasonable, non-discriminatory grounds. My hon. Friend discussed that at length and made it quite clear what the guidance says. In practice, a GP’s discretion to refuse a patient is limited, and a GP cannot refuse to register a patient just because they cannot provide identification or proof of address—that is unlikely to be considered reasonable grounds.

The European economic area confuses the issue further, but our obligations are simple. Each country is responsible for the cost of providing treatment for their own citizens while they are in other EEA countries, unless they are working. Workers are entitled to the same access to health care as that country’s own residents, on the principle that the country to which an individual makes social security contributions is liable for that person’s health care needs. In practice, that means we pay other EEA countries for treating our state pensioners who have retired there, and for the emergency needs of our own citizens who need health care when visiting another country, using their European health insurance card. The same is also true in reverse—other countries must reimburse the UK for treatment provided to their citizens. EEA nationals who come here to work are entitled to free NHS provision.

Overall, we pay out more than we receive, simply because many more of our state pensioners choose to settle in Europe than vice versa. This is sometimes the subject of large tabloid headlines, but it is important to make that point. We may see that change in the coming months. I acknowledge, however, that we need to do more to recover income due to us from other EEA countries for providing health care to their visitors and pensioners. We have an extensive programme of work under way to address that.

As the shadow Minister said, unpaid debts are a small amount of the total spent on the NHS. However, as my hon. Friend pointed out, £30 million or £40 million pays for a lot of treatment, a lot of care and a lot of medicine. Although it is a small percentage of the total budget, for an individual it is significant. We need to recognise that in any system that charges, debts are sadly inevitable. Guidance is clear that hospitals should not provide non-urgent treatment until a chargeable patient has paid in full, but they have a legal duty to provide emergency care. When a patient is responsible for repaying a debt, if a debt is incurred, the NHS has a duty to the taxpayer to recover that debt. Audited NHS trust accounts and data from Monitor show that last year, £14 million was written off due to unpaid debts—a small but significant amount for taxpayers. We are determined to reduce that write-off without compromising the provision of urgent treatment. My hon. Friend related the terrible story of the American visitor for whom the hospital could not even provide any documentation for him to claim from his health care insurer. The statistic of a third of NHS trusts not even pursuing debts is shocking. On the other hand, we have the example of West Middlesex, which is clearly doing an excellent job.

The hon. Member for Ealing, Southall expressed his frustration with some immigration and Home Office issues, and he is absolutely right to discuss the UK Border Agency. My hon. Friend the Member for Kingswood discussed the fact that GPs do not want to be gatekeepers on immigration issues. We are therefore reliant on UKBA to ensure that people who are entitled to be here are here, and that people who are not entitled be here are not here. He also made a distinction regarding foreign nationals who come here specifically to access NHS care. I remind the shadow Minister, probably because I am significantly older than him, that this issue goes back a great deal further than the previous Labour Government. It probably goes back further than previous Conservative Governments, which have to be thanked for making the NHS such an attractive option that people came here as health-care tourists a long time before 1997.

I share the concern and frustration of the hon. Member for Ealing, Southall about immigration status. I have a university in my constituency. A lot of foreign students try to regularise their status in this country and fail to do so—their passports are left with the Home Office for goodness knows how many months and the situation becomes very confusing. I think that the people he is talking about are in the grey area in the middle. We need to address this matter and will continue to work with the Home Office. To repeat for the record, the recently amended immigration rules state that a person with a debt to the NHS of £1,000 or more can now be refused a new visa or extension stay. That should not only assist in recovering more debts, but act as a deterrent against failing to have health insurance when visiting the UK.

[Mr David Crausby in the Chair]

[Mr Reed]

Will the Minister help with a genuine question about the new NHS commissioning arrangements? If clinical commissioning groups procure services from hospitals where that is a particular problem, what advice will the Government give them?

[Anne Milton]

It will bring the focus closer to home. I would expect the shadow Minister to welcome this change, because GPs will now be much more acutely aware that registration with them should not automatically entitle people to NHS acute trust care. We are undertaking a review that I will mention in my concluding remarks. It is early days in respect of the UK Border Agency and the change in the immigration rules, so we do not have sufficient information adequately to evaluate how effective they are, but I think that we will see a significant impact. The shadow Minister asked specifically about the Olympics.

[Jim Shannon]

The Minister said that £14 million in debts was written off by the Government. Do the Government contact the countries that people have come from to try to recover some of those debts, or is it too costly administratively to do that? Is it cheaper to write off debts than to chase them up?

[Anne Milton]

That is true of all debts. Trusts are not always aware of the rules and the obligations placed on them. Sometimes, they do not have the infrastructure in place to chase such debts and sometimes the costs of chasing debts are greater than the debts themselves, so they write them off. Either way, it is clearly not fair on the taxpayer. West Middlesex is an exemplar. We in the NHS are not good at sharing best practice, but practice at West Middlesex should be spread more widely.

Back in 2005, when the Labour Government were in power, as part of the UK’s successful bid for the 2012 Olympics they committed to provide games family members with free medical care. The games family is a tightly defined group of people—athletes and their support teams, officials, accredited media and IOC members—who are directly involved in taking part in or supporting the games. We have introduced a specific exemption for those people in respect of hospital treatment that might otherwise be chargeable, which will last for only nine weeks around the time of the Games and will be limited to treatment, the need for which arises here, so pre-planned or routine ongoing treatment that can wait will not be free. Normal charging rules will apply to all other visitors, including those coming to see the games.

The NHS has been briefed to be particularly vigilant in screening visitors who seek treatment and in applying the charging rules, given the large influx of visitors to the country. Let me reassure the residents of Hackney—the shadow Minister rightly said that Homerton is one of the designated hospitals—that treatment will be given on the basis of need. Local people should not suffer at all as a result of these rules which, as the shadow Minister will be aware, were an important part of the previous Government’s bid.

My hon. Friend has mentioned some of the details of our review. It is important that there should be qualifying criteria, a full range of other criteria exempting services or visitors from charges, and criteria for charging for services outside hospital, as we move towards more care being delivered outside hospitals. We need to be mindful of costs that could be incurred, thereby ensuring that we have more efficient and effective processes throughout the NHS, including the ability to screen eligibility. Let me reassure the hon. Member for Strangford (Jim Shannon) that it is important that we work closely with the devolved Administrations, and have close discussions with them, to ensure that there are not unforeseen and unintended consequences.

Once again I thank my hon. Friend the Member for Kingswood for introducing the debate, and I thank hon. Members for the balanced, moderate nature of the discussion. It is important that we set an example—all parties desire to do so—and demonstrate to the public that such difficult issues, which can involve distinct communities, can be discussed and considered in a fair and balanced way and are matters of cross-party concern, with all political parties working together. It is not becoming for any politician to score party political points on an issue of such fundamental importance to the taxpayers of this country.