NHS (Foreign Nationals)

Debate between Anne Milton and Jamie Reed

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.

Health Care (West Cumbria)

Debate between Anne Milton and Jamie Reed

Wednesday 16th March 2011 Westminster Hall

[Anne Milton]

I thank the hon. Gentleman for his remarks. It is frustrating for local people when they are waiting for decisions to be made. General elections come along, disrupt things and, sadly, slow down the process even more. I can understand his constituents’ frustration. Later in my remarks, I will address how we can move forward.

The hon. Member for Copeland was right to make the point that local NHS organisations are precious not just for the services that they provide, but for the employment and economic support that they bring to the area. I note, in particular, his work with the west Cumbria strategic forum and the development of the energy coast master plan for west Cumbria. The development of local NHS services plays an important role in that.

The hon. Gentleman will also know that in west Cumbria, as in other parts of the country, the NHS is under tremendous financial pressure. Indeed, he alluded to that. We are where we are; we have inherited a substantial deficit. Both parties acknowledge the fact that we face some serious economic challenges, and we are determined to find £20 billion in efficiency savings so that we can then reinvest in quality care, and the need to do that is real and urgent. Such pressures would have existed whoever was in government. The fact that we have protected NHS budgets is an important step in ensuring that the challenges facing the NHS are slightly less than those facing other areas. None the less, the upshot is that every NHS trust in the country will have to make tough choices to put health care on a sustainable footing, and that is what is happening in west Cumbria.

I understand that the North Cumbria University Hospitals NHS Trust has struggled financially for a number of years. Clearly, there are some unresolved issues that people are now keen to sort out. Like the country as a whole, the trust is on a journey to restore balance to its finances, and we need to consider how we get better value for money. When I visit hospitals and trusts, it is interesting to see how substantial amounts of money have been taken out of costs by small changes in the way services are delivered. Although this is a challenge, it is also an opportunity, and I am impressed with the innovation that people are demonstrating.

As the hon. Gentleman is aware, the trust concluded in February 2011 that it would not be in a financially viable position for achieving independent foundation trust status by the 2014 deadline. It has made the difficult choice to pursue an arrangement with an existing foundation trust, through merger or acquisition, to ensure its ability to deliver high quality services in the future. The trust reached that decision for a number of reasons, including reduced contract income as more health care is provided outside acute settings, historical debts, costs associated with the private finance initiative scheme, to which the hon. Gentleman alluded, and ongoing requirements to meet cost saving targets.

Having trained as a nurse and worked in the NHS for 25 years, including as a district nurse, I am acutely aware that although our focus is always on acute care the majority of health care is delivered outside acute settings. It is the tension and the co-operation between those two elements of health care that we must now finally get right. The trust must address the issues that I have just mentioned. In particular, it must identify and agree an affordable clinical model that will deliver sustainable high-quality services. It is no good going for short-term gains. We need the process to be sustainable and lasting.

The hon. Gentleman will know that, back in 2007, the NHS in Cumbria set out its plan to reduce unnecessary hospital admissions by looking after people closer to their homes, which is where they want to be. The closer to home programme supported the development of community-based services and the redevelopment of acute facilities to meet local needs. In support of that programme in Cumbria, there is the redevelopment of West Cumberland hospital, which will deliver acute services with support from a wider range of community services.

Following recommendations by the national clinical advisory team last year, I understand that the north Cumbria health economy is now working to develop an affordable clinical strategy, covering primary, secondary and acute hospital services. I understand that the strategy will be published this summer. I suspect that it cannot come soon enough for the hon. Gentleman and many others in the area. In many ways, the strategy will build on the closer to home programme by considering how local health care services can be delivered more affordably, while keeping service quality at the very highest level, which is critical. As part of that process, it is true that the review group is looking at what will happen to acute services at West Cumberland hospital.

During his tour of hospitals in Cumbria last year, my right hon. Friend the Secretary of State for Health acknowledged the importance of West Cumberland hospital to the local people. That view is shared by all of us and it is being taken into account by the Department of Health, the North West strategic health authority and the NHS in Cumbria, which is working on the full business case for the redevelopment of the hospital. That business case will need to reflect the clinical strategy. It is very important that these decisions are driven by clinical need and that they meet the needs of local people.

[Mr Reed]

The Minister talked about the trust’s unique responsibilities. Of course, one of the unique responsibilities that the trust must address is the unique service that west Cumbria provides to this country in the form of the nuclear industry, and the unique challenges that the industry poses for the trust. It is in the interests not only of my constituents but of the whole country that the issue is addressed, and it must be done on a cross-party basis. Would the hon. Lady care to say something about that?

[Anne Milton]

Yes. I thank the hon. Gentleman for that intervention. He is absolutely right to tie up the facts. As politicians, we tend to use the word “sustainable” in a rather flippant way, but what he has just said is what “sustainability” should be about. It should take account of the changing needs of the area; we should be building services not for the next five years but for the next 10, 20 or 30 years.

Tension between acute services and community services has always existed, as has tension between acute services and specialist services. If I think back to my own time in the NHS 30 or 40 years ago—I am very old and it was a long time ago—I recall that regional centres for neurosurgery were being developed. Specialist services need to be provided in specialist centres. Local people want to know that they can go to their local hospital for the majority of things that are wrong with them. That is important. There needs to be a clinical driver in the process, to ensure that people get the quality of care that they need. However, one also needs to take account of people’s wants and desires, and they want care on their doorstep.

The hon. Gentleman raised a number of issues. I recommend that he attends the debate that is happening elsewhere in the House today if he wants a fuller discussion of NHS services. He wanted a number of guarantees from me, so he wanted a number of guarantees from the centre and yet in the same breath he talked about “top-down” and “centrally imposed” diktats. Again, that is one of the key issues, because the centre is never very good at making local decisions. What matters locally is that changes and discussions have the support of clinicians, and ideally are led by clinicians. Those changes and discussions must also have the confidence of local people. That confidence is possibly what has suffered in the past.

The hon. Gentleman talked a little about GP commissioning, GP fundholding and “any other willing provider”. He asked what “any other willing provider” means. I suggest that he goes back to his own party to ask that question, because using “any other willing provider” was at one point its policy. I feel very strongly that the reforms in the NHS will bring decisions about commissioning and getting care right for people absolutely where they should be: with the GPs who know and understand their local communities. It is extremely important that GPs’ inputs and commissioning skills are used to the fullest.

I am told that the national clinical advisory team is reviewing the draft strategy and that a final version will be put to the strategic health authority in the months ahead. In addition, the full business case for West Cumberland hospital, together with the business cases for development of community services, will need to be considered alongside the final clinical strategy. I know that the delay is frustrating, but it is absolutely vital if the decisions are to be made. I or my ministerial colleagues will be very happy to have a meeting with the hon. Member for Copeland. In fact, it might be useful if a meeting was set up with a number of MPs from the area, to thrash out some of the more difficult issues when we have slightly more time to do so.

The process must be clinically led and choices must be made on clinical grounds. The primary care trust must also be satisfied that proposals are properly costed and can deliver sustainable solutions and a sustainable model of care for Cumbria. However, I emphasise that no final decisions have yet been made.

This is an important period in the story of the NHS. An ageing population, rising demand and increasing costs are combining to make it a uniquely challenging time. It is always challenging to deliver health care, with rising expectations and rising demands. That means that all parts of the country must look critically at how they can make the best use of resources to deliver effective health care, in whatever setting it can be most effectively delivered. It also means more care being provided in the home and in the community. I think most people see that development as a positive step, and there must be support for it. The difficulty is that realising cost savings ultimately means changing hospital services as demand changes. However, the NHS actually has a good history and a good record on evolving and changing to meet changes in demand and patient choice.