Immigration Fees for Healthcare Workers

Stuart C McDonald Excerpts

Monday 30th January 2023 Westminster Hall

[Stuart C. McDonald (Cumbernauld, Kilsyth and Kirkintilloch East) (SNP)]

It is good to see you in the Chair, Mr Sharma, and it is a pleasure to take part in this debate. I thank the hon. Member for Gower (Tonia Antoniazzi) for introducing the subject so comprehensively and eloquently, and I also thank her and her colleagues on the Petitions Committee for bringing it before us for debate in Westminster Hall. The Committee also did a great job in carrying out the survey that has helped inform some of the contributions that have already been made, and which I will come to shortly. I thank colleagues for those contributions, which have all been very powerful.

As colleagues have said, the starting point of this debate must be praising the international NHS staff. We have heard about the extraordinary contribution of those overseas nationals who come to join with UK nationals in order to keep our national health services “brilliant”—to use the word that the petitioners have used—and we have heard facts and figures about how significant the contribution of those overseas nationals is. Around one in six NHS staff members in England is non-British, and if I have understood the figures correctly, it is pushing on one in three doctors and one in four nurses. Overall, there are over 200,000 overseas NHS staff, coming from over 200 countries. GP practices are no different: we had a very constructive debate in Westminster Hall a couple of months back about some of the problems with keeping international medical graduates here as GPs, and the Minister took some points away from that debate. It will be interesting to see whether there has been any progress in the work being done to encourage more of those graduates to stay, because there is a gap in how the visa process works in relation to people wanting to stay on as GPs.

In particular, we should all recognise the extraordinary role that overseas workers in our NHS played during the pandemic, and indeed the sacrifices they made in protecting us from covid and treating those who suffered from it. I think I am right in saying that overseas nationals were disproportionately represented in the number of health workers who lost their lives during the pandemic.

The next part of the equation is, of course, that the NHS continues to face unparalleled challenges, particularly in terms of vacancies. Despite the huge contribution of the overseas workforce, figures also show that massive vacancy rates remain. As of September, NHS England had a growing vacancy rate of just shy of 12% for registered nursing staff: full-time equivalent staff vacancies in NHS trusts in England increased from about 133,100 in June to 133,400 in the quarter to September 2022, which I think is a five-year high. Overall, the vacancy rate in the quarter to September 2022 was 9.7%—again, a five-year high.

The important point, putting aside all the numbers, is what those vacancy rates mean in practice. Last year, a RCN survey found that only a quarter of nursing shifts have the planned number of registered staff on duty, which means that three quarters of shifts are going ahead with a shortage of nurses. In the ideal world, even if some nursing staff had to call in sick, we would have enough nursing staff to cover for them, but even with the full complement on, we are still short-staffed—we spend £3 billion every year on agency staff.

It is absolutely valid to say that the answer has to be partly about improving training and recruitment locally and ensuring that we can rely on the domestic workforce much more in the longer term. However, as the Health and Social Care Committee recently pointed out, overseas workers are essential to the health and social care system in the short term and in medium to long term: any move to shift to more domestic supply is likely to take time. We will have to continue to rely on overseas nationals filling those jobs in the years ahead.

[Margaret Ferrier]

Although health policy is devolved, visa and immigration policy is not, which means that the decisions of Ministers here in Westminster are having a direct impact on the devolved Administrations’ ability to build resilience in healthcare staffing and to resolve the crisis. Does my hon. Friend know how Ministers have sought to engage with the Scottish Government on this issue?

[Stuart C. McDonald]

I do not, but I would be interested to hear from the Minister about that. I will come shortly to how visas will impact on the Prime Minister’s and the UK Health Secretary’s own plans for turning the NHS around, but to put it succinctly: we can have all the action plans in the world, but they will be made significantly more difficult to implement if the recruitment shortages are allowed to continue.

The argument made a few times in Government responses during similar Westminster Hall debates is that the Home Office does not make a profit on ILR visas. That seems to defy the normal understanding of the word “profit”. The fact that the Home Office reinvests into other border and immigration functions is utterly irrelevant. The Home Office charge for that type of leave is several times the cost of processing the ILR application: it is a profit. Those profits have been increasing exponentially in recent years. Research by the Migration Observatory at the University of Oxford shows that since the £155 fee was introduced in 2003, it had risen to £840 by 2010 and now stands at £2,404. At one point during the debate, the question of why that is was asked: I will be brave enough to hazard a guess. To my mind, the reason is quite simply that the Home Office is one of the unprotected Departments sat right in the eye of the storm of austerity. Baroness Williams, a former Minister of State, pretty much said that in an answer to a written question:

“Application fees have increased in recent years as the Home Office aims to reduce the overall level of funding that comes from general taxation.”

The long and short of it is that the Home Office is struggling for money and has therefore been ramping up fees in an extraordinary manner over the past 10 to 15 years. As we have heard from various hon. Members today, that profit margin is having hugely negative impacts, including the uncertainty that it causes staff on the front line and the effect it has on their health and wellbeing, particularly during this cost of living crisis. We even heard about the dangers of debt and exploitation as a result. Ultimately, all that impacts on patient care. How can we look after patients properly when we are struggling to recruit staff while making it more difficult to retain the excellent staff we have already managed to recruit?

The Doctors’ Association UK has pointed out that the fee is more than many health professionals will make in a month and that it is pushing skilled staff to consider careers outside the United Kingdom instead. I turn to the survey of the Petitions Committee, which showed that 71% of foreign healthcare workers did not intend to apply for ILR because of the cost, with a further 28% saying, as has been pointed out, that they had delayed their application due to the costs involved.

[Rob Roberts]

Does the hon. Gentleman agree that it is not just the cost of the applications themselves, but all the supplementary stuff that goes with it? When my partner applied for ILR 18 months ago, he had to do the IELTS English language test again, which he had had to do when he came into the country. I am not sure that anyone will be able to convince me that his standard of English will have gone down since he passed the test on coming into the country. Why would he have to do it again? Going from doing an ILR application to citizenship 12 months later, he had to do biometrics twice and pay for them twice—often £100 or £200 just to go to an office, hand over documents and have someone say, “Thank you very much—we’ll be in touch.” Those other supplementary bits make such a huge difference.

[Stuart C. McDonald]

I absolutely agree. In terms of financial cost and complexity, it is so easy to put a foot wrong. Far too often in the process, when a foot is put even a tiny bit out of place it can result in someone losing their leave altogether, falling off the conveyor belt to settlement and not being able ever to get back on it. It can have dire consequences for people if they make one mistake in this complicated process. The hon. Gentleman makes a very powerful point.

In light of the Petitions Committee’s survey, the question is whether the Home Office and the Department of Health and Social Care agree that the fees are having such an impact. Are people deciding not to apply for ILR, or to put off their applications for it? If the Home Office does not agree that that is the implication of the high fee, on what basis does it reject that? Has it done research and decided that the fee does not have that impact? If so, can we see that research? If it accepts the implications of the Petitions Committee’s report, what is it going to do about it?

Otherwise, the Home Office is providing another reason for medical professionals to decide that it is no longer worth remaining in the UK, and to take their expertise elsewhere. There is evidence that recruitment agencies in Australia, Canada and elsewhere are aware of those challenges and are proactively advertising here to attract medical professionals. The British Medical Association believes that one in three junior doctors is considering a move abroad. That is all a function of the Home Office handing skilled staff an incentive to leave rather than stay.

That brings me to the point about fees in general—but this fee in particular. Our whole process of setting immigration fees has become absolutely obscure and is not subject to enough scrutiny. That is another reason the Petitions Committee should be praised for bringing the subject to the Chamber for debate. As it stands, the Home Office can lawfully take into account only the following criteria when it sets fees: processing costs; the benefits that will accrue to the applicant and others; the costs of other immigration and nationality functions, hence its profit; economic growth; international comparisons; and international agreements. There are problems with that framework that we should revisit, but we will come to that another day. There are problems with how it is applied in cases regarding children and families.

In another debate a couple of years ago, the point was made that it is the other way around with visit visas. We actually subsidise them. It will be interesting to know whether people who are applying for a visit visa are still paying less than the cost of processing that visa. It would be quite extraordinary if we were taking money from healthcare professionals and using that to subsidise folk to come visit. I understand that the Home Office wants to encourage visitors, but I think we would struggle to justify that arrangement.

Even if we just apply those factors to the visa for healthcare workers, it still makes sense to set a greatly reduced fee. We know that the processing costs are a fraction of the fee. As for the criterion about benefits that will accrue to others, the NHS is in crisis—what bigger benefit could there be than people to help get us out of the crises that we face?

We are also supposed to consider international comparisons. It would be interesting to hear what work has been done there. For example, on citizenship fees, the UK is a wild outlier in how much we charge folk for citizenship. I do not know whether the same is true of permanent resident fees. I suspect that it is, but I would be interested to know whether the Home Office has done research on that—otherwise I am sure that hon. Members will do that themselves.

We also have to speak about Brexit. My party thought that Brexit and the end of free movement was an utterly awful event. It does make a difference, because it makes it particularly difficult to attract NHS workers from the European Union. A talented doctor or nurse from any one of our neighbours has 27 other countries they can go to with barely the need to fill out a form, never mind pay a fee. The NHS visa helps—it is right to acknowledge that—but it does not change the fundamental position that we are less competitive in attracting people from our nearest neighbours. Until we fix those problems, we are going to struggle to recruit the people we need. All the action plans in the world— announced by the Prime Minister, the Health Secretary or anybody else—whatever their merits, are going to struggle to be fulfilled until we resolve that issue.

It is not just about the fees; other things have been raised. For example, my hon. Friend the Member for Rutherglen and Hamilton West (Margaret Ferrier) mentioned social care workers. We had a debate on the functioning of GP visas for international graduates; I would be interested to hear what further work has been done on that. We heard about families; that was not something I had thought about, but how we treat families is really important. We expect people to come and work, but to leave their families behind sometimes. That is completely illogical and counterproductive.

Some steps have been taken, which should be welcomed. The existence of the NHS visa is of course one of them. The non-application of the immigration health surcharge is another. I thought that this was a really powerful point: by taking those steps, we have encouraged people to come here to work; why do we now discourage them from staying? That seems utterly illogical. The Home Office has gone halfway down the road of treating NHS staff in a fair and supportive manner; let us just complete that journey.

A powerful case has been made by the petitioners. I acknowledge that this is not a straightforward matter for the Home Office. There are arguments as to whether a similar case can be made for others. But the hon. Members for Delyn (Rob Roberts) and for Streatham (Bell Ribeiro-Addy) made powerful points. The Home Office does make special rules for special categories all over the place. This is the most special of categories and it requires a bespoke response—something that the Home Office itself has argued by coming this far. Let us just complete that journey. The Home Office needs to look at the matter very carefully, because real damage is being done to the NHS now by persisting with this high fee, so I hope that the Minister will be open to engaging on the matter and will look again at the fee and listen sympathetically to the case that the petitioners are making.

--- Later in debate ---

[Robert Jenrick]

The hon. Gentleman makes an emotive point, but the reality is that we must fund our immigration and borders system somehow. We can either do that through general taxation, the fees that we levy through all the points of entry into the UK and our visa system, or we can find it through other means undetermined. We have chosen to do a combination of general taxation and the fees that we charge for our visas and immigration services. That is right, because we do not want to put further unsustainable pressure on the general taxpayer.

In a moment, I will come to the specific support that we have provided to health and social care workers, and how that sets them apart from almost all other recipients of our system. We have to fund this substantial cost one way or another, and it is right that a significant proportion comes from those who benefit from it. It is also important that we fund it appropriately, because it is in all our interests that the system operates efficiently. We have seen in recent years—as we have been in the long shadow of covid—how challenging it is when we are not processing visas and immigration applications appropriately. We also see every day how important it is to have a safe and secure border and a well-resourced Border Force and Immigration Enforcement system.

[Stuart C. McDonald]

At the crux of the matter are the figures produced by the Petition Committee’s survey, which suggested that significant numbers are deciding not to apply for ILR—that healthcare workers and others are putting off applications. Is that a problem that the Home Office recognises? If not, on what basis is it refusing to recognise that as a problem? If it does recognise that as a problem, surely it has to think again about the fee and its implications.

[Robert Jenrick]

I will come to that point in a moment, because I would like to answer it directly. We have given it careful thought and responded to it in recent years.

The petition rightly notes that the Government have taken significant measures to ensure that health and care staff are supported. Those measures have included automatically extending visas at no cost, refunding fees to those who have already paid to extend their visa, and a bereavement scheme that allowed relevant family members of NHS care workers who passed away as a result of contracting covid-19 to be granted ILR free of charge. As with any other visa or immigration product, we also provide a route for those in exceptional circumstances who cannot meet the costs.

Further to that, the Government introduced the health and care visa itself—the subject of the debate—back in August 2020, and extended the commitment in January 2021. It is a successful visa route in its own terms. The most recently published statistics say that 61,414 visa applications were made, which account for around half of all skilled worker visa applications to the UK in that period. The package of support we have built up since we introduced the route has made it substantially quicker and easier for eligible people working in health and social care to come to the UK with their families and, in time, to extend their leave.

The Home Office has worked closely with the Department of Health and Social Care to ensure that this support is as flexible as it can be. In my previous role—by happy coincidence—as the Health Minister responsible for the recruitment of nurses, care workers and clinicians to the NHS, I saw that at first hand when we met representatives of organisations from the UK and other countries with whom we were transacting. On that point, I would simply say that we take seriously our responsibility to avoid depleting of those individuals countries with most need of healthcare professionals, and have focused our efforts on countries that are able—where we can verify that—to export trained individuals to the UK.

A previous debate, which has been referenced, on barriers to the visa process focused particularly on GPs and smaller GP practices, which might struggle to navigate the system. My officials have followed up on these issues and are now working with the Department of Health, the BMA and others to explore whether there is demand for and practicality in pursuing an umbrella route for that area of the health service.

The application fee for a health and care visa is significantly cheaper than for wider skilled worker routes, with a visa for up to three years costing £247 and one for more than three years costing £479 for both the main applicant and their dependants. That amounts to around a 50% reduction on the equivalent skilled worker fees. There is also no requirement to pay the immigration health surcharge. The subject of dependants was raised earlier; the same reduced fee and faster processing times apply for dependants of health and social care visa holders, and dependants have access to all the other benefits as well. The offer was further improved when we added care workers to the list of eligible occupations in February 2022, based on a recommendation from the Migration Advisory Committee. I refer hon. Members to the delivery plan for recovering urgent and emergency care services, which was published today, and the work that the Home Secretary and I have been doing with the Health Secretary to deliver that.

The hon. Member for Gower referenced those who have sadly left the country in part because they could not afford the fees for ILR, which the hon. Member for Delyn restated in his intervention. When we introduced the points-based system, we removed the limit on time that an individual could spend on the skilled worker route. Under the old system, a person needed to be able to apply for settlement after six years, or they had to leave the UK. Under the current system, if a person is unable to apply for settlement for any reason—including, potentially, that they cannot afford to apply—they have the option to continue being sponsored until they are able to meet the requirements for settlement. There is absolutely no reason why an individual should feel compelled to leave the UK if they are not yet able, for whatever reason, to begin an ILR application.

[Robert Jenrick]

Although I appreciate the hon. Gentleman’s point, I do think it is an important to clarify that no one listening to or reading this debate should feel that they will need to leave the UK at any point; they can continue to remain here for as long as they are able to be sponsored, and should demand for health and social care services remain as high as it is today, it is very likely that they will be able to do so. However, I appreciate the wider point that those who come here for a sustained period of time and feel committed to the United Kingdom will want to progress to indefinite leave to remain and, indeed, citizenship. We in this Government and, I think, Members across the House do not take a passive view of ILR or citizenship; we want to encourage people to ultimately commit to the UK to the extent that they choose to become permanent residents and, indeed, citizens.

The proposal to waive fees for ILR, which is the substance of the debate, would clearly have a significant impact on the funding of the migration and borders system. As I said, we have in recent months been able to negotiate funding from the Treasury for a significant reduction in the initial visa fee, but any further reduction in income would have to be reconciled with additional taxpayer funding, reductions in funding for public services such as the NHS, or increases in other visa fees. Therefore, as much as one would want to do so, I am afraid that it would be very challenging for the Government to progress that proposal.

[Stuart C. McDonald]

The hon. Member for Delyn (Rob Roberts) made a very valid point: we have to look at the wider picture. As I mentioned, £3 billion is being spent on bank nurses to backfill vacancies, so by losing some money from the Home Office budget, we could be saving money for the NHS. We should not just look at this in isolation. There should be a cross-Government review of the implications for taxpayers.

[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.