Immigration Fees for Healthcare Workers

Janet Daby Excerpts

Monday 30th January 2023 Westminster Hall

[Tonia Antoniazzi]

I agree with the hon. Lady. The scheme has been extended by 12 months, but care workers are the lowest paid, and these are some of the biggest costs.

The numbers tell only part of the story. Although it is essential that we know the facts and figures, I would like hon. Members to think about what those numbers translate to for patients. Those clinical oncologists are helping to reduce the backlog of patients awaiting checks, scans and treatment, and are delivering life-saving care to cancer patients. Those midwives are guiding mothers through pregnancy and helping to bring their children into the world. Those doctors and nurses gave so much during the covid pandemic, worked all hours, did not see their own families, saved lives and comforted those who could not be with their families in their final hours.

[Janet Daby (Lewisham East) (Lab)]

During the pandemic, I was involved with GMB’s campaign for NHS cleaners and carers to be granted indefinite leave to remain after the sacrifices they made. Does my hon. Friend agree that we need to lower the cost of indefinite leave to remain and show the same level of gratitude to health workers who had to work during one of the most severe crises that our NHS has experienced?

[Tonia Antoniazzi]

It is true that these have been the most challenging of times, and indefinite leave to remain is one way of addressing that.

As we discuss the petition, I urge hon. Members to remember that when we talk about health and care workers, we are not talking in the abstract. We must remember the very real impact that Government decisions have on people’s health and wellbeing. There is little argument that workers from overseas are not essential to the running of our healthcare system. In fact, NHS trusts actively recruit from around the globe.

The health and care worker visa we are discussing was introduced to speed up processes to ensure that much-needed health and care staff could work in the United Kingdom. Despite broad agreement that there is obvious need in our overstretched health and care sector for overseas professionals, the current system is failing to retain these key workers. The expensive, drawn-out indefinite leave to remain process is pushing many key workers away, creating financial and bureaucratic barriers for those who wish to stay and to continue working in this country.

A greater number of healthcare workers settling in the UK would only benefit the health system. Not only does better access to ILR make the UK more attractive to the international workforce; better staff retention provides employers with greater long-term security for workforce planning, which I know at first hand is a key issue. Indefinite leave to remain allows for greater mobility between sectors and employers, as well as greater flexibility to deploy internationally recruited workers where need is greatest, rather than being hamstrung by restrictive visa requirements.

The financial barrier is high. The Migration Advisory Committee has highlighted the general high cost of these fees compared with other countries. The cost to apply for ILR sits at £2,404 per person. However, the latest visa and transparency fees data suggests that the estimated cost of an ILR application is just £491. In the context of a decade of pay erosion and the cost of living crisis, ILR fees may simply be unaffordable for many healthcare workers.

In the online survey of petitioners run by the Petitions Committee, respondents said they found it difficult to save up for indefinite leave to remain fees because of low salaries and a high cost of living, especially where they would need to pay ILR fees for multiple family members. One nurse who answered the survey said,

“I work as a deputy sister. I’m a single mum and my 2 kids have recently joined me in the UK. I cannot afford the ILR fees for me and my 2 children. With the salary of nurses and the cost of living here, a single mum like myself cannot afford it.”

A medical practitioner who responded said,

“As with current pay and cost of living crisis, it’s impossible to save this much. I am forced to buy used and second hand items only. I buy the cheapest groceries. Try and only use heating when absolutely required…I am forced to work weekends to save. I am hardly spending time with family. My mental health is affected. It feels like I’m a slave forced to labor…I don’t understand why the government would keep a fee that would force workers to leave NHS and UK…I survived through all waves of covid and staffing pressure. Had multiple illnesses because of my work. I don’t think I’ll survive this one. I believe these fees will break me.”

The fee is not the only cost; it is in addition to other substantial visa fees paid in the years prior to eligibility.

Workers without ILR are also subject to the no recourse to public funds policy. The cost of living crisis brings into sharp focus the potential financial hardship that internationally educated workers who are unable to access public funds could face. Members of the Royal College of Nursing consistently report the negative impact that the policy has had on their lives and the lives of their families. The covid-19 pandemic has exacerbated the challenges that individuals with no recourse to public funds were already facing, with these families identified as being at high risk of living in insecure and crowded housing.

Making the ILR process more accessible would bring significant benefits to individual workers who report that their mental health is suffering as a result of the financial pressures they are facing to try to meet the costs of ILR. A healthcare assistant who responded to the Committee survey said

“With the ever rising cost of living, [saving for ILR] becomes mentally draining for an already overwhelmed health worker. Reducing the cost shows the government care about the wellbeing of health workers and promotes work life balance because families have to work odd hours to meet up with the fees.”

The RCN also reports that nurses sponsored under the health and care visa often have difficulty reducing their working hours because of the minimum salary threshold —£20,480 per annum—that is applied to their visa. Given that there is no provision for that to be applied pro rata for part-time staff, the RCN understands that the policy often conflicts with nurses’ caring responsibilities.

Better settlement pathways can help to tackle abusive labour practices, reducing the ability of predatory employers to use immigration status to tie staff into exploitative situations. This is particularly relevant in the care sector, where the director of labour market enforcement has identified workers as being at high risk of exploitation. The RCN is aware from member reports that employers will, on occasion, use threats of deportation to coerce staff into paying extortionate repayment fees should they choose to leave employment early.

The current policy means that the UK is already losing overseas healthcare staff to other countries.

“I couldn’t raise the money [for ILR] for the last 2 years to apply, so I’ve gotten a better salary offer in New Zealand…so I’ll be leaving the UK.”

Those are the words of one nurse who responded to the petition. A trainee doctor told us:

“With paying for exams and training, I don’t have enough money to apply for an ILR, which makes me think to leave the UK and work in Australia after I qualify as a GP.”

The petition is not simply asking for a reduced fee for those health and care workers seeking ILR; it is asking for a joined-up approach from Government, and for a better system that will improve the lives of those using it and enable us to provide a strong and sustainable health sector.

Earlier, I told hon. Members that it was essential to remember that behind the figures, statistics and costings, we are talking about people, so I will finish by telling hon. Members about the person who kicked this all off—the petitioner, Mictin, who is here today with his family—and why he started the petition. Mictin was actively recruited to the NHS from India, as NHS trusts use local agents to recruit for them. Of the 23 other overseas workers who started with him when he came to Leicester, only six are still working in the trust. The costs of pursuing ILR were too much for many of them and some have found new work abroad—skilled workers who have left the United Kingdom because we have made it too difficult to stay.

We ask people to make the choice to come to the United Kingdom, but we have not ensured that we have a system that makes that choice an easy one. We force difficult choices on the workers we need. Mictin and his wife have made the choice to stay, but we have not made it easy for them. Mictin’s parents-in-law have never seen their grandchild, because the cost of taking him to India would mean greater delays in applying to ILR. Mictin started the petition because he knows he is not the only one making these difficult choices. While our health sector desperately needs more Mictins, we have to ask why we are making the choice to stay so difficult.

--- Later in debate ---

[Rob Roberts]

Completely; this is something I have debated. As I say, my partner is from the Philippines and, because of that, I now have a big extended family and friends who are Filipino and are overseas. They are all in the same boat. As I will explain in a moment, the type of things they have to go through, and the debts they get into, are ridiculous. I completely agree with the hon. Lady.

The NHS has played a vital role. Although the whole NHS deserves our thanks and gratitude, they should in particular go to our NHS workers who have come from overseas. They have travelled huge distances to be here, often separated from their families and putting their own lives at risk to help and save our lives—citizens from a different country to their own. Regardless of their or our citizenship, the duty to care and contribute to the wellbeing of others always comes first with them. It is amazing, and we as a society should highly commend it.

I welcome the number of steps the Government have already taken for foreign NHS workers, including the health and care worker visa and exemption from the immigration health surcharge, but we need to do more than that. These people want to make the UK their home. They put down roots—we have a duty to put in place a framework to allow them to do that without thousands of pounds in costs just to stay in a country to which they have already contributed so much.

[Janet Daby]

So many of my constituents have contacted me to say that these fees are absolutely too expensive for those in the healthcare profession. Why does the hon. Gentleman think the Government have kept the fees so high and have not lowered them?

[Rob Roberts]

The hon. Lady imputes to me knowledge that is far above my pay grade, but I am sure the Minister will be delighted to answer her when he takes to his feet later. I have no clue, but it is ludicrous. As the hon. Member for Gower (Tonia Antoniazzi) said earlier, the cost is £420-odd to process these things. I will come to the fees in a minute, but there cannot be any justification for that cost. Going back 15 years, it was a fraction of what it is now; the fees have increased at an exponential rate over the past five or six years. I am sure that the Minister can enlighten us on that later; I look forward to the answer.

Of course, it is worse in the part of the world of the hon. Member for Lewisham East (Janet Daby). The cost of living in my constituency in north Wales is significantly less than it is down in the London boroughs. The extra pressures and the compounding of that problem are much worse: I completely agree.

As we have mentioned, fees for ILR are over £2,400. Citizenship, 12 months later if so desired, costs another £1,800 or so, plus a few £100 for biometrics, English language tests and all the other supplementary things that have to be done. The naturalisation process costs more than £4,000. That is one of the most expensive in the world. The process of becoming a citizen for NHS workers is costly and challenging.

The process includes the ridiculous “Life in the UK” test. I am not sure whether anyone is familiar with that test: it is a wonderful thing. It asks questions such as, “Which palace was a cast-iron and plate glass building originally erected in Hyde Park to house the Great Expedition of 1851?”, “In which century did the first Christian communities appear in Britain?” and, “Which two British film actors have recently won Oscars?” Quite how anyone can be expected to properly integrate into British society without that pivotal knowledge, I have no clue, but there we are. They have to pass that sensible test.

In similar debates, I have told the tale of Carrie, a real-life case using a different name. She moved to the UK in 2016, leaving her husband and four-year-old child back home in south Asia. It took another year for her husband and daughter to join her because of the cost involved in a dependant visa. They could be together again as a family only once she took out a loan, which she paid for over the next three years. She had to get another loan three years later because she was due for a renewal of that visa, adding a load more fees.

In 2021, Carrie was entitled to apply for ILR. With loans still ongoing from previous renewals, what choice did she have? What could she do? She had to take another loan—even bigger than before—just to have the right to occupy a space in this country and call it home. She pays her taxes every month; she has done for years. She works in an intensive care unit. She has spent all her working life in this country saving lives, especially during the pandemic. As I have said before, she should not be in debt. We should be in her debt.

It is our duty in this place to create a new route for citizenship for NHS workers that will not leave them in debt, in poverty or—as the hon. Member for Gower said—in mental anguish with the constant worry of funding the next application. By reducing the costs associated with ILR and citizenship, and in time abolishing them completely, we can help to do just that.

I am proud that our NHS attracts global talent and recruits from around the world. Quite frankly, we would be—I was going to swear there—we would not be able to run it without them. We would be in difficulty. In 2021, over 160,000 NHS staff stated that they were of a non-British nationality, from over 200 different countries. That accounts for nearly 15% of all staff for whom a nationality is known. However, the current fees and process are a huge barrier to both future NHS workers, who are put off coming because they do not feel they will be able to stay long term, and to current NHS workers, who are unable to afford the final step to have the permanent residency that they have earned through service to our country.

Residency and citizenship should not be about cost. They should be about contribution and inclusion in our communities. NHS workers have perhaps given the biggest contribution of all by saving our lives and keeping us safe. If they are not citizens, they cannot be fully part of the communities in which they live and work, despite being such valued members. Without ILR, individuals face barriers to home ownership, as it is almost impossible to get a mortgage without it. It is difficult in the job market and higher education. There are barriers wherever we look. Reducing the fees, or even scrapping them entirely, would not only make residency and citizenship more achievable, but create a more diverse and, crucially, a more integrated society. People from other countries who have worked in our NHS during the pandemic and throughout their lives deserve to be able to call the UK their home, and actually feel like it is.

The pandemic has been horrendous, but it has had one benefit. It has highlighted what many of us already knew: our NHS workers, whether British or not, are the backbone of our health service and our country. Those who have come here to provide such incredible care should not be penalised for it, but the high application fees do just that. It is time to reduce, if not entirely abolish, the fees for ILR and citizenship for those who work in our NHS so that those who spend time helping and treating us can finally feel like they belong and are welcomed with open arms.

[Bell Ribeiro-Addy (Streatham) (Lab)]

It is a pleasure to serve under your chairmanship, Mr Sharma. I congratulate my hon. Friend the Member for Gower (Tonia Antoniazzi) on the way she laid out the debate.

Everybody should realise that the NHS has always relied on staff from all over the world. It literally would not exist without the contribution of doctors, nurses and NHS staff from outside the UK, starting with the Windrush generation, who were also treated terribly by this Government’s Home Office.

The NHS is currently in a dire state, and the industrial action being taken by care workers is a clear example of that. At the heart of the crisis facing our health service is the struggle to recruit and retain healthcare staff, and the cost of living makes that even worse. Some healthcare workers who are paid less are having to use food banks, and in-work poverty is even greater for migrant workers due to the cost of living.

Reducing the cost of visa applications for overseas healthcare workers seeking indefinite leave to remain is not only just and fair, particularly for their families, but it would address the recruitment and retention crisis in the NHS by encouraging overseas workers to remain in the profession. It lacks humanity and economic sense to leave those key workers living in perpetual uncertainty about whether they can remain in the UK. They have to pay extortionate fees to do so, but they are working and contributing to the economy of this country.

The Government have repeatedly argued—the hon. Member for Delyn (Rob Roberts) said this too—that not giving special treatment to NHS workers is about creating a level immigration system, but our immigration system has never been equal and the people making applications have never been treated the same. That is reinforced by the Government’s points-based system. A millionaire who wants permanent residency in the UK can move things along a lot faster just by putting millions in a bank account in the UK. There is a shortage occupation list. There are thresholds for being able to bring family members over. We differentiate between people who have ILR and certain visas on the basis of whether children they have here are automatically granted British citizenship. We have never treated everybody equally, and on top of that we charge some the immigration health surcharge—even NHS workers.

Several healthcare professionals from across the country, both from migrant backgrounds and not, support this petition. I will talk about what one of them said to me. It costs £2,400 for an ILR visa, but he is being asked to pay 10 times more for his family. That family of four is being asked to pay £12,000 just to have indefinite leave to remain. He said:

“NHS staff get recruited to work in terrible conditions. We can’t pay our bills, and then we’re charged thousands of pounds just to stay here and work. Given the terrible NHS staff shortages, this policy reaches next-level stupidity.”

I agree with that doctor. We cannot afford to lose doctors such as him, especially when other countries are taking steps to attract them. We have already heard about how some people are leaving us. Given the shortages of NHS staff in this country, we simply cannot afford that. We will tackle the chronic shortages only by treating all staff decently.

The Government have explained again that they are maintaining their hostile environment—I know they call it something else—to make the country less attractive to people who want to enter it illegally. Obviously, I take issue with the people they term “illegal”, but they are also making it hostile for people who, by their own definition, are legal. How does that make any sense? Those people have been asked to come here to support our services. We are not talking about people who are visitors, or who want to take from our country. We are talking about people who are saving people’s lives—who are working in our NHS daily, who saw us right through the pandemic. Those people have left their own countries to come and serve ours, and they are doing a fantastic job.

[Janet Daby]

My hon. Friend is making an excellent speech. Does she agree that the Government are behaving in a rather ironic way by encouraging people from skilled professions and backgrounds to come to our country to work, but then making it very difficult for them to settle?

[Bell Ribeiro-Addy]

My hon. Friend is absolutely right. Why are we making overtures to people in other countries and waiting for them to come here, only to treat them with complete contempt and disrespect and leave them in really serious situations where they are trying to support their families, and also making it difficult for their families to remain here? We all understand how important it is to have our families around us, but as we have already heard, some people have to leave their families behind and then face unreasonable barriers to bringing them into the country.

These people are doing so much for us, coming to our country to serve us as NHS workers at all levels: doctors, nurses, cleaners and porters, and let us not forget our social care workers. We need to make sure that we are treating them with the respect they deserve, no matter where they happen to have been born.

--- Later in debate ---

[The Minister for Immigration (Robert Jenrick)]

I am grateful to the hon. Member for Gower (Tonia Antoniazzi), who opened the debate with a characteristically constructive tone, and to the Petitions Committee for sponsoring the debate. It gives us the opportunity to discuss this important issue, and I recognise the high degree of interest evidenced by the thousands of people who signed the petition. Like the hon. Member, I welcome Mictin to this Chamber, and thank him and others for creating the petition and bringing it to our attention.

The Government provided their initial response to the petition in February 2022 and I am pleased to respond again today, having listened carefully to the many thoughtful contributions. Let me say from the outset that we are extremely grateful for the contribution to the national health service and the whole country made by the many NHS workers who have come here from all over the word—not just in recent times, but from the very foundation of the NHS, as was rightly said earlier, including the early generation of Windrush arrivals.

Although we want to see better domestic recruitment, training and retention of healthcare workers—as others have said, it is essential that we build more healthcare places at UK universities and colleges in the years ahead —it is fair to say that international workers will continue to play a significant role in the NHS for many years to come. It is for that reason that the Government have taken a number of steps to support those individuals coming to the UK, and their employers here in their efforts to recruit them. We want to ensure that the UK is a welcoming place for them and that they are provided with all the support they need as they enter the UK, make their significant contribution to the NHS and, in many cases, choose to make a life here with their families, moving through our immigration system from indefinite leave to remain to citizenship in the years that follow.

[Janet Daby]

I hope the Minister will come on to the point of biometric residence permits, but I want to draw his attention to the fact that when NHS workers come and their biometrics keep being delayed, it prevents them from engaging in society, such as being able to open a bank account or get their kids into school; there is such a knock-on effect. Could he say something about the Home Office’s ability to manage and speed up that work, so that there is an immediate effect for NHS workers?

[Robert Jenrick]

I would be more than happy to say something on that now in answer to both the hon. Member and the hon. Member for Delyn (Rob Roberts). As I understand it, the Home Office is meeting its service standards on biometrics, but none the less I have had correspondence from a small number of colleagues across the House who have said that recent arrivals in the UK are struggling to obtain appointments. I have taken the matter up with my officials, and have asked them to improve the quality of the service. If the hon. Lady has specific constituents who are struggling to get the service they want, I would encourage her to come to me. The hon. Member for Delyn made the point about individuals repeatedly providing their biometrics with each application. I am told that although the Department is increasingly using more robust biometrics, we have started reusing biometrics to reduce the need to reprocess them time and again, so I hope that issue will decline over time.

Let me turn to the main point of the petition: the cost of indefinite leave to remain. ILR is one of the most valuable entitlements we offer, and the fee for the application generally reflects that. Fees are set in line with the charging principles set out in the Immigration Act 2014, which include the cost of processing the application, the wider cost of running the migration and borders system, and all the benefits enjoyed by a successful application. The Home Office does not profit from these fees. All income generated above the estimated unit cost is used to fund the wider migration and borders system and is vital for the Home Office to run a sustainable migration and borders system that keeps the UK and all of us safe and secure.

The published full operating cost of our migration and borders system in 2021-22 was £4.8 billion. The fees under debate today are significantly lower, but they make an important contribution to the whole body of work that goes into an efficient and safe borders system.

--- Later in debate ---

[Robert Jenrick]

It was for that reason that we took the decision to apply a 50% discount to the initial visa fee, taking into account the broader benefits for the public sector and the taxpayer of bringing more people into the country through a faster, simpler route. I have not seen evidence that individuals are leaving the country because they cannot access ILR at the present time, but if the hon. Gentleman has research suggesting there is a material issue, I strongly encourage him to bring it to my attention or that of the Department of Health and Social Care.

[Janet Daby]

Will the Minister give way on that point?

[Robert Jenrick]

I am happy to give way, but I should then draw my remarks to a close.

[Janet Daby]

Two weeks ago, I met second year medical students studying in our country. The majority said they are not planning to remain in the UK to practise as doctors because of the various pressures and strains on the NHS, feeling undervalued and so on. It is therefore likely that we will continue to need people from overseas to work in our NHS, so—on the same thread on which the hon. Member for Cumbernauld, Kilsyth and Kirkintilloch East (Stuart C. McDonald) spoke—we need to do more and make it easier for people to support our treasured NHS.

[Robert Jenrick]

The hon. Lady makes a valid point. Of course, we want to retain as many NHS professionals as possible, whether they grew up in the UK or have come subsequently from overseas. There is a significant challenge with individuals choosing, for a range of reasons, to go to other countries; of course, we in Government have to balance that with broader affordability, taking into account the cross-Government cost and how we would replace that income from general taxation.

Turning to international comparisons, the fees that we charge are broadly comparable with those of other developed countries. There are, of course, competitor countries that charge less, as there are those that charge more. Taking as examples some countries that, anecdotally, doctors and nurses frequently go to as opposed to working in the UK, our ILR fee is higher than that of New Zealand, but lower than that of Australia. It is not clear that the fee in the UK is substantially higher than in those destinations that healthcare professionals might otherwise go to. The hon. Member for Delyn implied that there had been a substantial increase in our fees over recent years, but that is not in fact the case. The ILR fee has increased by £15 between 2018 and the present day, so we have tried, as far as possible, to keep the costs under control in recent years.

The hon. Member for Delyn also asked about the “Life in the UK” test, but I am afraid disagree with him on that point. Integration into UK society, knowledge of our history and pride in our country are extremely important. The previous Labour Government’s decision to introduce the “Life in the UK” test was right, and we have supported it consistently in government. Long may that continue, because it does make a small contribution to encouraging people to better integrate and understand the country to which they are committing.

I again thank the hon. Member for Gower for introducing the debate and all hon. Members who spoke. There is no doubt that we are in agreement on the importance of the NHS and its workforce. We care deeply about those individuals who choose to come here from overseas; I pay tribute to them and thank them for their service. I hope I have set out some of the ways the Government are working to ensure that their time in the UK is as fruitful as possible, and that, if they choose to make a life here, that is as seamless as it can be within the confines of our fiscal situation and affordability for the taxpayer. I assure all hon. Members that we will reflect carefully on the points that have been raised in the debate, and that we will continue to do what is necessary to support our fantastic NHS.