Immigration (Health Charge) (Amendment) Order 2018

Baroness Williams of Trafford Excerpts

Wednesday 28th November 2018 Lords Chamber

Moved by

[Baroness Williams of Trafford]

That the draft Order laid before the House on 11 October be approved.

Relevant document: 3rd Report from the Secondary Legislation Scrutiny Committee (Sub-Committee A).

[The Minister of State, Home Office (Baroness Williams of Trafford) (Con)]

My Lords, since its launch 70 years ago, the National Health Service has transformed the health of the nation and established itself as one of this country’s greatest assets. Our NHS is always there when we need it and those who live in this country contribute to the long-term sustainability of the service over their lifetime. The NHS is the envy of the world and will always be free at the point of delivery.

The immigration health charge represents the most cost-effective and fair means of ensuring that temporary migrants make a financial contribution to the operation of the service. Doubling the charge will still ensure that official health costs associated with migrating to the UK remain lower than or comparable with those of other nations, including those in Europe, North America and Australasia. The charge is paid by non-European Economic Area temporary migrants who apply for a visa for more than six months or apply to extend their stay in the UK for a further limited period. It is paid up front as part of the immigration application process and is separate to the visa fee.

From the point of arrival in the UK, a charge payer can enjoy the same access to the NHS as a permanent resident. They can use the full range of NHS services without incurring treatment charges and without having made any tax or national insurance contributions in the UK. They generally pay only those NHS charges that a UK resident would also pay.

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[Baroness Williams of Trafford]

I am talking about the United Kingdom, so I am talking about the devolved Administrations as well—I think. Yes, I am. I thought it was a trick question and so doubted my own mind. Going back to what temporary, non-EEA migrants might have to pay for, they generally pay only those NHS charges that a UK resident would also pay: an example might be prescription charges in England. They will also be charged for assisted conception services in England, should they choose to use them.

The charge rate has not increased since its introduction in 2015. It is currently £200 per year; students and youth mobility scheme applicants enjoy a discounted rate of £150 per year. To date, the charge has raised over £600 million for the NHS. Income is shared between England, Scotland, Wales and Northern Ireland using the Barnett formula. That answers the noble Lord’s question.

The draft order amends Schedule 1 to the Immigration (Health Charge) Order 2015, to double the annual amount of the charge across all routes. Students, dependants of students and youth mobility scheme applicants would continue to pay a discounted rate, which would rise to £300 per person. The annual amount for all other relevant application categories would rise to £400 per person.

The Department of Health and Social Care has reviewed the cost to the NHS of treating charge payers in England. It estimates that the NHS spends, on average, £470 per person per year for all migrants who pay the charge. This calculation includes those surcharge payers who actually use the NHS and those who do not. Where the cost has been calculated on the basis of those who use the NHS, the figure rises to £1,300 per person per year. This means that temporary migrants are currently paying the surcharge at a significantly lower rate than the amount it costs to treat them each year.

The proposed new charge level is intended to better reflect the costs to the NHS of treating those who pay it. However, it is important to note that it will remain below average cost recovery level, in recognition of the wider contributions that migrants make to this country. It will also continue to represent good value compared to health insurance requirements in other comparable countries.

The charge should not be conflated with the system of hospital treatment charges for overseas visitors provided in NHS legislation. That provides a separate framework for recovering treatment costs from short-term visitors and those without lawful status. The NHS charging system observes the important principle that immediately necessary or urgent medical treatment is never withheld, irrespective of the patient’s status.

The Government believe it is fair that temporary migrants make a financial contribution to the comprehensive and high-quality range of NHS services available to them during their stay. The charge will remain a good deal for migrants. Even at the increased rates, they will still pay less than it costs the NHS to treat them. By increasing the charge, the Government estimate that a further £220 million a year could be generated, helping to protect and sustain our world-class healthcare system for everyone who uses it. By way of illustration, England’s share of the additional income could fund around 2,000 doctors or 4,000 nurses. I commend this order to the House.

Amendment to the Motion

Moved by

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[Baroness Williams of Trafford]

My Lords, I thank all noble Lords who have taken part in this debate.

First, in virtually every country in the world, all migrants who move to a new country expect to pay towards their healthcare. In most countries this is usually in the form of medical insurance or through up-front payments when accessing healthcare. Many countries require health insurance as a condition of a migrant’s visa. For example, all foreign fee-paying students applying to study in Australia or New Zealand are required to hold acceptable medical insurance as a condition of their visa.

Healthcare can be needed at any time, regardless of age or profession. Anyone who has purchased healthcare insurance will know that it will likely cost more for those most at risk, such as the elderly, the very young or those with long-term health conditions. As noble Lords will know, that is not the system we operate in the UK. Our NHS does not charge more to those who need it most. However, everyone must make a contribution towards the costs of the NHS, to ensure that we all have access to care when we need it. It is therefore right that migrants who have access to the NHS in the same way a British citizen would if they needed it, pay a fair share towards it.

[Lord Teverson (LD)]

The point is, as the noble Baroness, Lady Jones, said so well, that all those other jurisdictions the Minister has mentioned do not pay for their health services totally through national income taxation, which is paid by migrants in this country. That is the fundamental difference and is the whole point of the argument.

[Baroness Williams of Trafford]

I will give an example: if I went to America and worked there, I would pay taxation but would also pay health insurance. It is no different.

[Lord Teverson]

It is completely different.

[Baroness Williams of Trafford]

I think we will have a disagreement on a point of principle, but if the noble Lord could let me outline the Government’s position—I will certainly take interventions at the end—I will explain why temporary migrants coming to this country get a fair deal.

A number of noble Lords have raised the issue of NHS professionals and how they ought to be exempt from the charge. The Government fully recognise the contribution that international healthcare professionals make to the UK, but it is only right that they also make a proportionate contribution to the long-term sustainability of the NHS. In that regard, NHS professionals are in the same position as other providers of essential public services, including teachers.

I recognise that there are concerns about the financial impact on nurses. However, the answer is not to exempt nurses from the charge but to increase their pay. This is happening. All NHS nurses will benefit from a pay increase as set out in the Agenda for Change framework. It is important to remember that the charge offers access to healthcare services that are more comprehensive and at a lower cost than those in many other countries. Most professionals who choose to work overseas need to have the appropriate medical insurance in place, which is the point that I made to the noble Lord.

Paying the charge ensures that the income generated goes directly to NHS services, helping to protect and sustain our world-class healthcare system for everyone who uses it. I am conscious of the concerns regarding the combined cost of the charge and visa fees. However, the charge is set at a competitive level and will remain low compared to the potential benefit, which is free access to the NHS. It offers better value than private medical insurance where the premiums are more expensive. As a matter of interest, I looked at the average insurance cost for the average American, which is $320 per month—significantly more than we would expect to pay. The Government are clear that migrants must pay the charge when they make an immigration application and should plan their finances accordingly. The costs of both the health charge and the application fees are available online and should not come as a surprise.

Many noble Lords spoke about vulnerable groups. We are committed to ensuring that vulnerable groups can access the NHS without charge. There are several groups applying for leave to remain in the UK who are exempt from the requirement to pay the immigration health charge as set out in the Immigration (Health Charge) Order 2015, and they continue to apply. They include people who apply for leave to remain relating to an asylum or humanitarian protection claim, and would absolutely include people who the noble Lord, Lord Hylton, spoke about, such as refugees, victims of modern slavery and children in local authority care.

Those who are exempt from paying the immigration health surcharge or who have the requirement waived are treated the same as those who have paid it, so they are entitled to virtually all NHS care free of charge. Noble Lords, including particularly the noble Baroness, Lady Lister, and the noble Lord, Lord Rosser, talked about how the requirement to pay up front could discriminate against those on low incomes. As I have said, the charge is set at a competitive level and is low compared with the potential benefit of free access to the NHS. Migrants are aware of the rules when applying for a visa, including the need to maintain and accommodate themselves in the UK, pay the health charge—and ensure they plan their finances accordingly. As I have said, and as noble Lords have mentioned, there are exemptions available.

A number of noble Lords talked about children. I am aware of the concerns raised about the impact of increasing the charge on children. Children are as likely as adults to use NHS services; as such, it is only fair that their parents or guardians contribute to the cost of their care. The Government continue to ensure that those who are most vulnerable are protected. Where an application fee is waived on destitution grounds the surcharge is also waived and, as I have mentioned, exemptions are in place for children in local authority care.

The noble Lords, Lord Paddick and Lord Rosser, talked about nurses.

[Baroness Lister of Burtersett]

The Minister is moving on to another issue, but could we stick with children for a moment? A number of noble Lords made the point that these children are not temporary migrants. At the outset, following an intervention, she said she would explain how temporary migrants get a fair deal. Then she said that migrants are aware of the rules when applying for a visa—but we are talking about children who are here, who have been here for some time, and who want to stay here. Could she please address that point?

[Baroness Williams of Trafford]

If you intend to be here temporarily, you apply for a temporary visa and you are captured by the immigration health surcharge, but clearly if you have indefinite leave to remain or are a citizen of this country, the health surcharge no longer applies to you.

[Baroness Lister of Burtersett]

But the point is that, to get leave to remain, people have to pay over 10 years and, as noble Lords have said, that amounts to over £10,000 when you add in this new surcharge. Therefore, it is making matters very difficult. It is a Catch-22 situation, is it not? How do the children get to show that they need to remain if they cannot afford it and the ability to afford it is being reduced by the health surcharge attached to the fee?

[Baroness Williams of Trafford]

My Lords, in estimating the charge, we estimated the cost of providing healthcare to someone who is here temporarily. The cost was estimated at £470 per person. To answer the point raised by the noble Lord, Lord Rosser, we decided to set the charge at £400 and not at full cost recovery because we recognise the contribution that migrants make to this country. We have not set the charge above cost recovery, as the committee had suggested.

I realise that the surcharge might make an application very expensive but we think that it is proportionate, given the access to healthcare that people will avail themselves of, and of course it is considerably cheaper than if they were to have private healthcare insurance. I am not decrying the fact that it might be expensive for a family—I appreciate that—but it is significantly cheaper than if they were to have private healthcare insurance, and of course the people concerned generally come here to work. I do not decry the fact that it is expensive; I am saying that, first, it is significantly cheaper than what we might pay for private healthcare as migrants going to any other country and, secondly, the service that they will get from the NHS once they have paid the surcharge has to be taken into account.

[Baroness Lister of Burtersett]

I am sorry to push it, and I promise not to do so again, but a number of noble Lords have pointed out that there is no child rights impact assessment, even though I think that one was promised in response to a Written Question. Can the noble Baroness undertake to take back to the Home Office the concern raised here so that in future, whenever regulations affecting children are brought before us, the impact assessment will include a proper assessment of the impact on child rights and not the cursory words to which the noble Lord, Lord Russell, referred?

[Baroness Williams of Trafford]

I can certainly undertake to take this away and provide for the noble Baroness and other noble Lords a more fulsome illustration of the impact. I have an illustrative example of a nurse and I can write to noble Lords with that.

[Baroness Jones of Moulsecoomb]

Before the noble Baroness returns to her response, I want to say that it is not appropriate to compare this country with places such as America, because we have a national health service and they do not. The point about our National Health Service is that it helps us to have a healthy and perhaps happier population, and that is good for everybody: it is good for the Government and for every single person who lives here. Therefore, it is not a gesture of good will from the Government to create a good National Health Service; it is imperative to our democracy.

[Baroness Williams of Trafford]

My Lords, I gave the example of America precisely because we have a national health service. Were I to migrate to America for a job, I would have to have healthcare insurance at a huge cost. The noble Baroness is right. There is a huge disparity in healthcare outcomes in America between those who can afford health insurance and those who cannot, and I am glad that we have an NHS for that very reason.

[Baroness Jones of Moulsecoomb]

My point was that we are not taking into account the wider implications of immigrants paying into our tax system, but then charging them on top of that. To me, that just does not seem fair.

[Baroness Williams of Trafford]

As I said earlier, if I went to America and paid my taxes, I would still need health insurance on top of that. The point I am trying to make about the surcharge is that, compared to what one might pay for private healthcare insurance in most countries, this is a very reasonable charge to access what I think is one of the best healthcare systems in the world.

[Baroness Jones of Moulsecoomb]

You are not going to convince us.

[Baroness Williams of Trafford]

No.

[Lord Paddick]

I do not want to prolong the agony for the Minister, but the point about America is that the tax people pay there does not pay for healthcare. That is why people have to have insurance. Immigrants come to this country, get jobs and pay national insurance and income tax, which pays for healthcare. But only immigrants have to pay a charge in addition to the national insurance and income tax they pay to fund the health service. Can the Minister explain why?

[Baroness Williams of Trafford]

Temporary immigrants have to pay the healthcare charge, but anyone with indefinite leave to remain or who is a citizen of this country contributes to the NHS through general taxation. We are not going to agree on this.

[Lord Lansley]

I cannot bear that assertion being put on the record without being refuted: American taxation pays for healthcare—it pays for Medicare, Medicaid and the CDC. American public expenditure on health is nearly as large, as a proportion of GDP, as British expenditure on health. It is just incredibly inefficient. As my noble friend says, those who travel to America and work do not get access to Medicare or Medicaid.

[Baroness Williams of Trafford]

I am glad to have a former Health Secretary standing behind me to put noble Lords—and me—absolutely right.

[Lord Russell of Liverpool]

Will the Minister come back to the point I raised about the inadequacy of the information we have about how effective the fee-waiver system is?

[Baroness Williams of Trafford]

I will. I will not give him an adequate response, but I will tell him why; if that is okay.

The noble Lord, Lord Rosser, asked why the charge was set below cost recovery levels. I think I have answered that. He asked why the estimate in 2015 of £800 per person is so different from what we have now. It is because in 2015 it was just that, an estimate. We can now give an actual figure, given that people actually use the health service. The noble Lord also asked why we decided to double it on the basis of Department of Health and Social Care analysis. He will know that we made a commitment before the 2017 general election to triple the surcharge. We have not; we have doubled it. It was because we had made a manifesto commitment that we did not consult on the issue.

The noble Lord also asked about EU citizens. We are in the process of negotiating reciprocal healthcare arrangements with the EU. We have reached agreement on citizens’ rights that will protect EU citizens and their family members who are resident in the UK by the end of the planned implementation period on 31 December 2020. We have made it clear that the immigration health surcharge will not apply where EU citizens make immigration applications during the implementation period after the UK leaves the EU. We will set out our plans for the future border and immigration system in a White Paper later this year, which, noble Lords will work out, has not long left. Another noble Lord asked that question. I will not pre-empt or trail the White Paper with further detail at this stage.

We have been through the double taxation argument. I do not think that the noble Lords who asked about it agree with me, but I have made the point that the charge is fair not only to migrants but to UK national and permanent residents who have or will make a greater contribution to the NHS over their working life.

The noble Lord, Lord Paddick, and the noble Baroness, Lady Jones, talked about the compliant environment. This is nothing to do with the compliant environment. The charge is intended to ensure that temporary legal migrants make a fair contribution to the cost of their healthcare in the UK. In contrast, the compliant environment is a suite of compliance, deterrence and data-sharing measures that form part of our overall approach to deterring and tackling illegal migration and protecting public services.

The noble Baroness, Lady Lister, asked why children do not feature in the impact assessment. This is because it is at a macro level rather than an individual level. I know she does not like that answer but individuals are fully catered for in the system of fee waivers and exemptions, and a child is as likely to need healthcare as an adult.

[Baroness Lister of Burtersett]

I know I said I would not come back to this issue but no impact assessment deals with individuals; they deal with groups. An equality impact assessment would deal with equality groups. A child’s rights impact assessment is supposed to inform us, not whether they are more or less likely to have healthcare, but what the impact is going to be on the rights of that child. All I was asking for was an assurance that future regulations have a proper child rights impact assessment as a part of them.

[Baroness Williams of Trafford]

I take the noble Baroness’s point because in everything we do with law, we have to consider the rights of the child. That is a basic requirement on the Government. It may be implied, it may not be, but I entirely take the noble Baroness’s point.

The noble Lord, Lord Rosser, asked me about undocumented children having to make four applications over 10 years at over £10,000. These applicants fall within the scope of specified human rights applications for which fee waivers are available—we have gone over that point—but, of course, parents may apply for the fee waiver for the child.

We have produced the policy on equalities assessment and will provide it to Peers who have spoken in this debate and place a copy in the House Library. I cannot stand at the Dispatch Box and say that it includes children. I suspect from what the noble Baroness says that it does not, so I go back to my previous point.

The noble Baroness asked about the chief inspector’s report and when it will be published. The immigration fees and the surcharge are obviously two separate things. The Government made a manifesto commitment to increase the surcharge and it is important that we deliver on that.

The noble Baroness also asked about the proportion of applicants receiving a waiver—this goes to the point made by the noble Lord, Lord Russell of Liverpool—but we have not published that information. However, we are reviewing the process because, as time goes on, these issues necessarily become more complex. I know that does not answer entirely the point made by the noble Lord, Lord Russell, and the noble Baroness, Lady Lister, but we will be reviewing that.

[Lord Russell of Liverpool]

On the point I made that in the impact assessment there is a reference to the Government considering options for families who are experiencing hardship, what options are the Government considering and where are they in their thinking?

[Baroness Williams of Trafford]

I cannot give the noble Lord any more information on that at this point but I am sure it will be released in due course. He also asked about the Coram freedom of information request. The first response was based on management information from a live database which is subject to variations as the year progresses. The second was not answered because of a policy to release only published information. Government departments often do not release information if it is not published information, although I have given management information with caveats before. The Government are seeking to resolve this issue.

[Lord Russell of Liverpool]

Does the Minister accept that it is extraordinarily difficult for us to try to work out the effects and the effectiveness of the fee-waiver system in the absence of any reliable or up-to-date data? How can the Government make decisions about it if they do not have the data? If they do have the data, please can they share it with us?

[Baroness Williams of Trafford]

We do not share management information data because it is purely that—management information. As I understand it, we are seeking to resolve this issue with Coram Children’s Legal Centre, and when we do I will be happy to write to the noble Lord with the outcome.

I hope that noble Lords are satisfied with my response, although I suspect they are not, and that the noble Lord will feel happy to withdraw his amendment.

[Lord Rosser]

I thank the Minister for her response. I did not get the impression that she was particularly excited about some of the things that are presumably in the brief in front of her when she responded to the numerous questions that have been asked. Nevertheless, she always—and I mean this—seeks to respond to the questions raised. We are grateful for that—and I mean that too.

I also thank all noble Lords who have participated in this debate. It seems quite a long time ago that I moved the amendment. I do not intend to make another lengthy speech or go through all the points. I was certainly struck by the view of the noble Lord, Lord Lansley, that it is a bargain. Whether he believes that it is a bargain for young children, which is one of the issues mentioned in my amendment, I do not know. Obviously, from the way he said it, I assume that he does, but I and some other noble Lords fundamentally disagree with his view. On that score, though, I respect his opinion and the arguments that he made.

During this discussion and in the response we have had from the Minister on behalf of the Government, great stress was laid on estimated costs and how the charge has been looked at against estimated costs. Very little was said about looking at the income of some of the people who will have to pay those costs. It is all being looked at from a cost point of view; it has quite obviously not been looked at from the point of view of the impact on the total incomes of those who will have to pay the charge, not least of those in low-income families.

[Baroness Williams of Trafford]

I apologise for intervening on the noble Lord. I said that I would write to noble Lords with an illustrative example of a nurse, if that helps.

[Lord Rosser]

I appreciate that the Minister said that she would write. I would be very grateful indeed if, when she writes, she will address this issue of the impact of the charges on the incomes of those who will have to pay it, particularly those on low incomes and with families with children.

There is another example of the way that the Government look at the issue. When reference was made to the impact on nurses, the answer was: “You solve it by increasing pay”. Yes, there has been a small increase in nurses’ pay, but there have not been very big increases over the past eight years. The charge is being doubled but I do not think that nurses’ pay is being doubled. I do not think that nurses will necessarily feel that the relatively small increase they have just had—they have not had much over the past few years—will be any real compensation for having to pay, for one specific item, a doubled charge. One does not get the impression that the Government have looked at this from the point of view of the impact on incomes, particularly for those among the less well off.

I think I heard a comment—I will withdraw my remarks if I am incorrect—which almost seemed to say that when low-income families are faced with this additional charge, it is up to them to arrange their finances accordingly. That was the thrust of the argument and how it came across to me. That is another indication that this has not been looked at from the point of view of the impact, particularly on people on low incomes and with children.

I am grateful to the Minister for saying that she will write. I hope she will perhaps reflect further on the point made by the noble Lord, Lord Russell of Liverpool, and my noble friend Lady Lister about the child rights impact assessment. I hope she will address that issue in her response on behalf of the Government. I know that she will give examples, but I also hope that she will reflect further on looking at the fee-waiver rules on destitution. “Destitution” implies that one must be in a pretty desperate state before receiving any assistance. The figures on the numbers of those getting the waiver appear to bear that out. No doubt the Minister will give examples in her reply—without indicating who she is talking about or anything like that—of the kinds of situations and income levels to which those fee-waiver rules have been applied up to now. At least then we could get a feel for the issue.

The answer given on why there had been no public consultation rather took my breath away. Apparently, it was because there was a manifesto commitment to £600. That seems an extraordinary reason for saying that there will be no opportunity for people to comment on what the Government are doing in the sense of how it will apply and its impact. I would have thought that any Government would want to put something like that out for consultation to get responses from people on the impact of such a doubling of charges.

I was very surprised to find that we have a Government who believe that they should not do any further consultation on the impact of something—not the principle of whether they will do it—and on how they might mitigate that because of a figure in a manifesto that they intend not to keep but to put at a lower level than is in the manifesto, which I am not complaining about. However, if the argument is that people voted for an increase in the charge to £600—it is difficult to believe that votes in the general election were determined solely by that—then they have not got what they voted for because the charge is less than that. Again, I am not complaining about that. I find it extraordinary that that was used as a reason for not consulting and giving people an opportunity to comment on the impact on certain people of doubling the charges.

I raised the issue of the child rights impact assessment. As I said, I hope the Minister will address that in her response. I will bring my comments to a conclusion. We opposed this matter in the Commons, where the order was agreed to in a vote. I tabled my amendment today to emphasise our continuing serious concerns about the impact of this increase in the immigration health charge but it is not my intention to press it to a vote.