Immigration and Social Security Co-ordination (EU Withdrawal) Bill (Eighth sitting)

Maria Caulfield Excerpts

Thursday 28th February 2019 Public Bill Committees

Brexit will introduce the biggest change to UK immigration policy in decades and it will present a huge challenge to an already struggling NHS, including the risk of NHS trusts incorrectly identifying EU nationals as being ineligible for NHS care and so withholding treatment from them. There has been no evaluation or consultation within the NHS on the impact that this change will have on already overstretched NHS staff and resources.

[Maria Caulfield (Lewes) (Con)]

The hon. Gentleman makes a valid point. Having worked in the NHS, I know that such checks cause additional pressures. But how does he suggest that the NHS pays for treatment for non-UK citizens? It is a national health service, not an international health service.

[Stuart C. McDonald]

We could do what we did previously, which was to recover the costs after the event. However, as I say, I have tabled these amendments to spark debate. At the end of the day, if it is a choice between risking people’s lives or even causing death, and risking losing out on certain funds after the event, the second of those is the lesser evil. However, it is a difficult issue; I do not have all the answers as to how we should approach it. As I say, that is why the new clauses and the amendment have been tabled.

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[Kate Green]

I wish to speak to amendment 37, which has my support, as do the new clauses in this group. I would like to say a few words about one particular aspect of NHS charging, which is in relation to maternity care. Under the current charging rules, non-urgent care must be paid for in advance, but “urgent” or “immediately necessary” care must be provided whether or not a person can pay in advance. The guidance from the Department of Health and Social Care and the statutory regulations make it clear that maternity care is to be regarded as immediately necessary, so it must not be refused or delayed if a woman is unable to pay in advance, although she will still be charged for it. However, because of confusion about the charging regime and misapplication of the rules, pregnant women who are not UK nationals have already been denied maternity care, told that they must pay in advance of receiving treatment or told that their appointments may be cancelled if they fail to pay. Extending the charging regime to EU nationals, including pregnant women, would multiply such injustices in a system that is already making serious mistakes.

Charges for NHS maternity care start at approximately £4,000 and can rise into the tens of thousands for more complex care for women or additional care for new babies. Those charges are significantly higher than what NHS trusts would normally be paid for providing such care, because the regulations require them to charge 150% of the relevant NHS tariff. In practice, the rules mean that some hospitals have sent bills demanding immediate payment of thousands of pounds from vulnerable post-partum women. Women have received letters threatening referral to debt collectors, local counter-fraud specialists or the Home Office; in one appalling case, a woman was issued a bill of almost £5,000 for treatment following a miscarriage.

Research by the charity Maternity Action has found that the charging regime has resulted in women avoiding essential antenatal care and missing appointments because they fear incurring a debt that they cannot pay or being reported to the Home Office. That includes women with health conditions that require effective management to protect the health of both mother and baby. Antenatal care is intended to pick up and treat problems as early as possible, increasing the chances of a safe and healthy birth. Missing midwifery appointments means that high blood pressure and gestational diabetes are left untreated, the window for HIV prophylaxis is missed and minor infections are allowed to develop into serious health conditions.

Migrant women who are entitled to free NHS care are also affected by charging policies. Maternity Action regularly encounters women, including EEA citizens, who have been wrongly assessed as chargeable and have received bills for their care. In some cases, the women affected by the rules have children and spouses who are British citizens. Surely that was not the intention of the policy.

In December, the royal colleges issued a joint statement calling on the Department to suspend the charging regulations pending a full independent review of their impact on individual and public health. The Royal College of Midwives has expressed

“enormous concern…that vulnerable women are missing out on essential…care.”

Given the harm that charging for NHS maternity care is already causing to women’s physical and mental health, the fact that many women are simply unable to repay bills, the clear lack of regard being given to children’s best interests, the risks to public health and the potential for the charging regime to be extended to all EEA nationals, is it not time to consider the arguments for immediately suspending all NHS charging for maternity care?

[Maria Caulfield]

Having had experience of looking after migrants in the health service, I have some sympathy with the hon. Lady’s argument, but who will pay for their care? Will it be the UK taxpayer, or will migrants have to make some contribution to their own healthcare needs?

[Kate Green]

I very much respect the hon. Lady’s expertise in these matters; I also appreciated her important comments during the Committee’s oral evidence sessions. I echo the hon. Member for Cumbernauld, Kilsyth and Kirkintilloch East. Clearly, there is a balance to be struck between the costs to the UK taxpayer and what is right for the health and wellbeing of anyone living in this country, in whatever circumstances. Like him, I would strike the balance on the side of health, wellbeing and the protection of life when we have to make those difficult choices.

As the hon. Gentleman said, there are things that we could do. One possibility, although personally I do not favour it, would be to apply the health surcharge in some circumstances in which it might not otherwise apply. However, the evidence is that because these women are unable to pay the debts anyway, most of the money will in fact go uncollected. The NHS is not really gaining financially. All the charges seem to do is deter women from seeking the care they need for themselves and their babies, and that is a false economy down the line. If the women are legitimately in this country, as they are, the need for further emergency care and primary care will pile up if they have not had the proper antenatal and maternity care that they should have had to meet their best interests and that of their children.

I know that the Minister takes these matters seriously. Will she use her good offices to ask her colleagues in the Department of Health and Social Care to publish the Department’s 2017 review of the impact of amendments to the NHS charging regulations? I am told that it engaged with those involved in the maternity care of women, including the Royal College of Midwives, but the outcome of that review has not been published and placed in front of us. If the Minister can do anything to persuade her colleagues to make that information publicly available, it would be much appreciated.

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[Caroline Nokes]

I am grateful to the hon. Members for Cumbernauld, Kilsyth and Kirkintilloch East and for Paisley and Renfrewshire North for tabling these amendments on migrants’ access to healthcare in the United Kingdom. I am also grateful to the hon. Member for Wolverhampton South West for tabling her new clause. Given their similar effects, I will consider them together.

The Government have been very clear in everything we have said since the referendum that, although the United Kingdom will be leaving the European Union, we are certainly not leaving Europe. Our relations with the European Union and the whole of the EEA will continue to be close and cordial. As part of that, immigration from the EEA will certainly continue. We want EEA citizens, who have contributed so much to our society, to continue living and working in the United Kingdom. While they are here, they will of course need access to healthcare. We are fortunate in this country to have a world-class health system, thanks to the NHS. The proposals, in different ways, would exempt EEA and Swiss citizens from the requirement to pay for healthcare in the UK. However, they are unnecessary.

Amendment 37 and new clause 12 are also technically deficient, because they do not reflect the nature of devolved health legislation. Entitlement to free-of-charge NHS care is not, and should not be, based on nationality. It is based on a concept of ordinary residence in the United Kingdom. For EEA nationals, that means living in the UK on a

“lawful…properly settled basis for the time being.”

I thank hon. Members for their comments on specific proposals, and I will make a number of points. Operating fair and proportionate controls on access to the NHS is not about outsourcing immigration control; it is about protecting a vital taxpayer-funded service from potential misuse. The Department of Health and Social Care’s policy of up-front NHS charging for non-urgent treatment for overseas visitors was upheld by the courts in a judicial review last year. Treatment for specified public health conditions, such as the infectious diseases mentioned earlier, is not subject to overseas visitor charges.

The hon. Member for Wolverhampton South West asked whether it was fair that EEA nationals should pay the health charge, given that they would pay for the NHS via taxes and national insurance contributions. Whether EEA nationals pay the health charge following the introduction of the new skills-based immigration may depend on the outcome of our negotiations with the EU about our future relationship. The health charge currently applies only to non-EEA temporary migrants. Although some non-EEA nationals will pay tax and national insurance contributions, they will not have made the same financial contribution to the NHS that most UK nationals and permanent residents have made or will continue to make over the course of their working lives. It is therefore fair to require them to make an up-front and proportionate contribution to the NHS.

When we debated this in Committee some months ago, the issue of the level of contribution was raised, and it has been again this afternoon. The Department of Health and Social Care undertook a careful study with NHS England of the NHS resources that temporary migrants to this country generally used over the course of a year. It came out in the region of £470 per individual. I hope that hon. Members will note that the immigration health charge is set below that level at £400 per person, or the reduced rate of £300 per year for students and those on youth mobility schemes.

The hon. Member for Stretford and Urmston raised maternity care. The Department of Health and Social Care is responsible for guidance on overseas visitor charges in England. Maternity care is always urgent and must never be withheld pending payment. That is clear in the Department of Health and Social Care’s guidance. However, charges are applied to protect maternity services for those entitled to live in this country.

The hon. Lady asked whether I would speak to DHSC Ministers about the review of charges, which I understand has not yet been published. I am happy to make that representation to my fellow Ministers.

[Maria Caulfield]

I thank the Minister for giving way; I know I have made a number of interventions now. Does it sound fair that Opposition Members are asking low-paid UK taxpayers to underpin the NHS services for EEA migrants, given that they often struggle to pay their tax and national insurance? Does she agree that, given that the health service is struggling to pay for drugs such as Orkambi for cystic fibrosis patients, it cannot afford to take on free healthcare for EEA nationals too?

[Caroline Nokes]

My hon. Friend makes an important point, which underpins the immigration health surcharge. The Government took the view, and in successive general elections made it very clear, that we would continue to implement and, indeed, increase the immigration health surcharge. As I said, this is a matter for EEA nationals and is still for negotiation as part of our future relationship.