§ 3.5 p.m.
§ Baroness Boothroyd rose to ask Her Majesty's Government whether they will consider the case for tighter regulations relating to the free treatment on the National Health Service of overseas visitors.
§ The noble Baroness said: My Lords, the announcement by the Government of a review of the current regulations on the eligibility for NHS treatment of overseas visitors is warmly welcomed by me. Given that the rules were established as long ago as 1989—long before the current era of mass migration, cheap fares and global information—I believe it is time that they were updated.
§ Obviously, emergencies occur and people fall sick while visiting this country and, for those, we must do what we can morally and legally. But we cannot be expected to deal with those who come here for the deliberate purpose of using the health service at the expense of the British taxpayer. Unfortunately, it seems to have become known that, if you can reach the UK, you can present yourself for a check-up, testing and treatment.
§ I recommend to your Lordships a splendid documentary produced by the BBC, which gives chapter and verse on how those from many parts of the world are able to operate the system and, at the same time, sets out the almost impossible situation in which overseas patient officers find themselves in recovering the costs of that treatment or pursuing those costs when patients fly home immediately afterwards. Overseas patient officers have a very difficult and sensitive task to perform, and we should all wish them well in the job that they do.
A debt recovery agency, CCI Legal Services, claims that some £50 million to £200 million is lost to the NHS every year through the non-recovery of charges. I fully understand that the Minister could not confirm that figure when I raised it in a Parliamentary Question. When asked about it, John Reid did not dispute the figure but said:
The debt amounted to hundreds of millions of pounds".
§ The department cannot give a figure because, regrettably, it does not collect information at the centre. That, to me, is a disturbing revelation.
§ Hospital managers are required to collect data on a host of issues from ethnic monitoring to performance targets. So why cannot the Government find out and state publicly how much is spent by the NHS on the 951 treatment of overseas patients? I submit to your Lordships that it is, after all, public money and it should be transparent and accountable. I trust that the new regulations will mean that public resources used in this way will be made accountable by the Department of Health.
§ Information provided for me by friends in the medical profession illustrates case after case where we have become a soft touch. I shall not weary your Lordships but shall mention only a few. There is the case of the Libyan lady who was admitted to hospital for two-and-a-half weeks and left owing £8,000. She was so ill on arrival that the consultant, my friend, asked her son, who was there at the time, how she had managed to travel in that condition. The son replied, "I flew with her into London yesterday, brought her to the emergency department this morning, knowing she would be taken care of for free. You see, I know the ropes".
§ A Mexican lady spent most of her hospitalisation in intensive care and left with a bill of approximately £40,000. So incensed was my friend that he wrote to her in Mexico asking for some repayment of the debt. For his trouble, lie was heavily criticised by the Race Relations Board and accused of racial harassment.
§ An American gentleman, another person who came here without health insurance, spent time in intensive care. His wife left him and flew back to the States. The amount owing at the time of repatriation was £56,000 for treatment, with an additional £5,300 for the cost of returning him home, paid for by the NHS trust.
§ I believe that we are all aware—I have been aware for some time—of the Nigerian lady with a history of difficult pregnancies who came here, it is believed deliberately, to give birth. She herself was seriously ill, as was her baby. Subsequently she left the country leaving her baby still in our care, and it is claimed, with a bill in the region of £500,000.
§ This is but a snapshot, and there are very many more eases, where families fly sick relatives in from overseas, claiming that the relatives have lived with them for years and therefore are entitled to free NHS beds. I am certainly pleased to learn that those loopholes will now be closed.
§ I turn to the attitude of the British Medical Association, which I find somewhat puzzling. Although the BMA has been in consultation on this issue for some months with the Department of Health, when the new rules were announced, John Reid was accused by the chairman of the BMA's international committee of "using a sledgehammer to crack a nut when we don't know the size of the nut". My response to the chairman is that those in the medical profession know the size of the nut. It is those working in the profession itself, many of them BMA members who frequently experience the problem and provide people like me with information to raise Parliamentary Questions and debates such as this because of their concern.952
§ Contrary to some myths being spread, fearing that doctors will be required to police the new system, John Hutton, the Health Minister, has made it clear to the BMA that doctors will not be expected to interrogate patients about their eligibility for treatment. That is the job—and will remain the job—of overseas patient managers. As I understand it, the BMA has a longstanding commitment to support principles and measures to minimise fraud and deliberate abuse of NHS resources. That being the case, I trust the association will welcome the strengthening of the regulations.
§ I turn now to those doctors compelled to speak out because their departments are at crisis point because of sexually transmitted diseases. A doctor at Doncaster Royal Infirmary claimed that the hospital was getting as many HIV cases in three months as it expected to get in two to three years and was at saturation point. A consultant at John Radcliffe Hospital, Oxford, NHS trust expressed similar frustrations while the Leicester Royal Infirmary evidenced a rise in its HIV-positive patients of 61 per cent over the past three years, with more than half the patients having resided in the UK for fewer than the required 12 months. Quite properly the department has made it clear that those undergoing treatment will continue to receive treatment. That is as it should be. Will the Minister say, once the new regulations are in place, how they will operate in relation to new entries into this country?
§ In recent times there has been much comment about the enlargement of the European Union and the demands that may be made on our social structure of families seeking to settle here. At the eleventh hour I see that the Government have built in some restrictions. But what of the demands made on the NHS? Are there any plans to allocate further resources to the health service in selective areas of settlement to meet the needs of families, particularly the young and the elderly from where the demand will be greatest? I never understood why we could not adopt the line of our major partners in the European Union, such as France, Germany, Italy and Spain, in seeking and obtaining a derogation, or some form of quota system, thereby making it easier to assimilate and to give effective aid and support to new residents. I can conclude only that those who did the initial negotiations for Britain must have been half asleep at the time.
§ I have never taken out a personal health plan; I rely entirely on the NHS. But of course, like many of your Lordships, I have insurance when I go abroad, not expecting the taxpayers of my host country to fork out for any treatment I might need. Is there not some way that visitors coming to this country could be made aware that they will be expected to pay for treatment, with their costs being met by either personal insurance or by their own department of' health?
§ I raise this issue because, like millions of other citizens, I rely on the health service and am proud of that service, and I seek to protect and cherish it. Equally, we in this country are proud of the way that 953 we have demonstrated a welcome to the troubled and destitute. It would be a great pity if the goodwill of this nation were stretched to breaking point. I welcome the proposals to introduce new procedures and look forward very much to the Minister's response.
§ 3.16 p.m.
§ Baroness Howells of St Davids
My Lords, I am sure your Lordships will agree that this is a very important and opportune debate. I thank the noble Baroness, Lady Boothroyd, for securing the debate.
I have always believed that tolerance hangs by a thread. I am concerned that some sections of the media have demonstrated the sort of xenophobia I thought we had got over in Britain after the Macpherson report. The media attack overseas visitors who are bent on exploiting our NHS with allegations of "health tourism". The press have mounted a sustained attack on immigration, with campaigns against "benefit tourists" and asylum seekers that allegedly jump council house waiting lists and take advantage of our very good National Health Service.
We, as decision-makers, have to be very careful not to breathe oxygen into the fire of intolerance, however good our intentions. The brunt of this hysteria will be borne not only by visitors coming to this country, but also by ethnic minorities who live here legally and those currently seeking asylum.
I should like to bring some calm words into this hysteria by recounting a story I heard some time ago. I owe the dates for this story to the noble Lord, Lord Tebbit, and would like to register my thanks to him for his good memory. President Reagan met the Japanese Prime Minister in 1987. I believe that the president asked the Prime Minister why it was that the Japanese economy was thriving at that time. The Japanese Prime Minister responded that it was due to the fact that Japan kept its employment market and welfare services open to its own people and closed to everyone else. That was hugely controversial at the time, as your Lordships may remember.
Today—2004—the economists tell me that the Japanese economy is not doing very well. But we all know that the multi-ethnic American economy is at the top. I would say, "So much for the closed shop doing better".
I should like to set out some facts. Accusations of "health tourism" should, I believe, be replaced with heart-felt thanks for the help British patients receive from economic migrants.
Home Office figures for 2003 show that 44,443 health care staff are from countries outside the European Union. They were all issued with work permits last year, a 27-fold increase on the number 10 years ago. The vast majority are nurses—more than 27,000 were recruited in 2003. The chief source is the developing world, with the Philippines topping the league last year with permits issued to 8,749 health workers; closely followed by India, with 7,367, and 954 South Africa with 4,422. In the UK, the numbers coming from overseas are still a tiny proportion of the 1.3 million NHS staff, but they are a vital element to the health service, and it cannot afford to do without them. The BMA says:Overseas medics have a vital role to play. It takes 10 years to train a GP, and about 15 years to train a consultant, so even if the government is pouring money into recruitment now, the effects will not be seen for many years".There is no doubt that we exploit overseas workers. We should be grateful that they are rescuing us from the failure of 10 years ago to invest in our home-grown health service.
We are right to promote our tough asylum and immigration laws, but we should be more reticent as a nation about trumpeting the success of the growing army of immigrants who perform an invaluable role in the health service. The efforts of these overseas staff counter the charge that immigration is imposing an unacceptable burden on our most valued institutions. This salutary statistic offers a stark and irrefutable snapshot of the vital role played by foreign workers in this country. It is a similar story in so many other sectors of the modern British economy. Immigrants fill every role in the health service, from doctors and nurses to pharmacists, radiographers, and occupational therapists. They work where British professionals are often reluctant to work, in traffic-choked inner cities and grimy housing estates. They perform the essential caring tasks that their British counterparts are reluctant to take on.
I will provide one example. I do not know this young man, but he is close to someone who I know very well. We will call the young man Sam. He is American. He works as a marketing consultant, and his work has taken him to Asia, Australasia and Europe. He lived and worked in London for years, before moving to Sydney and then back to London. He was about to go on holiday two weeks ago when he became so ill that he went to a London hospital. Within hours, he was diagnosed as being HIV positive and as having pneumonia. He was isolated and cared for night and day by the staff. He later found out that his diagnosis was AIDS in its late stages. His CD4 count is in the low 30s. He has been advised by his carers not to travel, and certainly not to fly.
I am pleased to say that the treatment received by Sam under the National Health Service means that he is now making steady progress, and he is out of hospital and about to start a drug trial. But for the care that the young American received these past few weeks from our NHS, he would now be dead. Incidentally, I am told that two of his nurses are South African, one is Nigerian, and one of his doctors is a New Zealander. He is making great progress; he is out of hospital and will be working again and paying, I am told, many pounds in taxation into the British economy. I hope that when we consider the case for tighter regulations we will bear in mind people such as Sam, a visitor to this country. I am very proud of my country and am pleased that we can send him back to his mother having benefited from a service free at the point of need.
955 What about the casual labourers who work in the UK? When I think of those poor, unfortunate cockleshell-pickers in Morecambe Bay the other week, I wonder whether the same journalists who lambasted so-called health tourists would have been so benevolent had all those poor Chinese people survived but required medical care. We benefit from sharing employment in the NHS with overseas visitors as we benefit from the NHS sharing its care with those unfortunate enough to call upon its aid while visiting, living or working in our country.
When I was very young, I read Matthew 14:16–21, in which the disciples say:We have here but five loaves, and two fishes".Jesus commanded the multitude to sit on the grass, and they were able to feed everyone. It states that,those that had eaten were about five thousand men, besides women and children".I often think of the mother who remembered to pack a lunchbox for the carrier of the five loaves and two fishes, and, more importantly, the young person's wish to share. I may be old-fashioned, but I feel that only good can come from sharing and being open. Let us dwell on that before we start restricting and closing; we could possibly be the losers.
I ask the Minister to assure this House that its laws will remain fair and just at all times.
§ 3.27 p.m.
§ Lord Rea
My Lords, with the leave of the House, I shall say a few words in the gap, as few speakers have put down their name to speak this Friday afternoon. Of course, that has nothing to do with the importance of the topic. I received my briefing rather late yesterday, so I missed the 6 p.m. deadline to add my name to the list of speakers.
I do not claim any expertise on this topic. As a general practitioner, I tended to treat all those who were even temporarily resident in the UK, especially if they were relatives of permanent residents, and I referred them if they needed specialist help. A few of those were then asked to pay for their care, depending on how zealously the hospital gates were guarded by the administration. The primary care of visitors is very difficult to police, and most GPs adopt a flexible approach. They certainly do not want to take on the gateway function of entry to the National Health Service itself, in addition to their current appropriate role of acting as a gateway to secondary or hospital care.
The position of the BMA, which has been quoted by most of those who have spoken, is clear. In its submission to the Department of Health in October last year on the proposed changes to the 1989 regulations, it expressed,concerns about the difficulty, in some cases, of distinguishing between genuine and fraudulent claims and the need for some degree of flexibility in operating any new system".956 It further expressed concerns,about the health care needs of very vulnerable visitors to the UK who were unable to pay for essential treatment such as the healthcare needs of failed asylum seekers awaiting deportation".That is very important.
Quite apart from any humanitarian concerns, failed asylum seekers who have untreated TB represent a hazard not only to their own health but also to the general population with whom they come into contact, and they are a very high-risk group. Leaving infectious diseases untreated can become problematic for wider society.
Until a patient has been registered and examined, it is not possible to establish such a diagnosis. That is a strong reason for allowing a very flexible approach. In its briefing, the Department of Health states:At present there are no specific arrangements relating to charging for primary care, although GPs have been given guidance on how to respond to overseas visitors who seek to register with them".In fact, that guidance is not new: it was most recently updated at least four years ago.
The guidance is complex as to who is and is not entitled to primary care. The response of most GPs and practice managers is to be flexible, as the BMA suggests. The BMA states:It is the BMA's view that doctors should not, in any way be charged with the task of determining whether individual patients would qualify for free NHS healthcare in the UK. In fact, following the BMA's expressed views on 30 December, the Department of Health has confirmed that doctors will not have to determine eligibility for treatment under the new arrangements for controlling access to free NHS care, a move welcomed by the BMA".I hope that my noble friend will be able to confirm that.
This is not an easy subject. By tightening up the rules, there is a danger that injustice may be done, often to the most vulnerable. I congratulate my noble friend Lady Howells on pointing that out so movingly. Thus, there is a potential danger of infection remaining undetected and untreated, to our detriment.
§ 3.32 p.m.
§ Baroness Thomas of Walliswood
My Lords, this subject has attracted a lot of interest in both Houses recently. The noble Baroness, Lady Boothroyd, is to be congratulated on her persistent and energetic referral to this topic on a number of occasions, including Starred Questions in October and December.
I agree that this is an important topic that should not be neglected. I also agree with the noble Baroness, Lady Howells of St Davids, that we must be careful not to carry regulation in this very delicate area too far. It would not be in accordance with our tradition over many years of generosity towards people coming into this country, nor is it the clinical tradition of UK health services to be excessively keen to reject people coming to the health service in perhaps acute need of care.
957 I am pleased that the Government are updating the 1989 regulations. But since they were issued, the number of different categories of people coming to this country has increased enormously. There are entitled and unentitled people coming from the EU perhaps accompanying visitors who are entitled, but who try to claim care on the NHS although they are not entitled. There are asylum seekers. There are students and their families. There are migrant workers and their families.
It is worth noting that NHS employees coming from overseas—to whom the noble Baroness referred—cannot get free NHS care for their relatives if they live abroad, although sometimes the overseas NHS workers attempt to seek such care for free.
There are also people who come here on six-month visas. They register with the local GP in the way discussed by the noble Lord, Lord Rea, and they try to use NHS hospital services. They are ineligible to receive free hospital care, but if they work in, say, a local bar and pay their tax and national insurance, they then become eligible for free hospital care like any other taxpayer.
So the situation is very difficult for hospitals, since it is at that level that the major costs are incurred. I am informed that not all chief executives treat this problem with the same degree of seriousness, either because they are not aware of the number of cases, or because they are aware of the difficulty of collecting the debts incurred if they treat patients free of charge. Not all know the size of the nut, to use the words of the noble Baroness.
My supplementary question to the Question tabled by the noble Baroness on 22 October last concerned the depth of the Government's understanding of the numbers involved, the costs and levels of debt recovery. However, that question went unanswered.
The hospital of which I was once a non-executive director has an efficient system for managing the reception, assistance, treatment and ultimate repatriation of its non-eligible overseas patients. Perhaps that is because the hospital is sited virtually next door to one of the major London airports. Despite the best efforts of the hospital team, current debt this year is a substantial sum. I shall not give the actual figures because I believe that they may not be public knowledge at this stage. Nevertheless, that debt is a small proportion of the total debt of the hospital at this stage in the financial year, when debts and credits are being balanced. However, one of the problems is that this debt is very difficult to recover. Only around 50 per cent of the debts incurred by overseas patients are ever recovered.
There are some serious individual cases. One woman has arrived here and, through no fault of her own, is now costing the hospital something like £20,000 to treat. The hospital does its best to deal with such cases. Sometimes, for example, it is cheaper to send applicants for free NHS care back to their country of origin with a medical attendant than it is to 958 treat them in the hospital. On rare occasions, that is how the problem has been dealt with—but only if patients are well enough to be treated in this way.
However, the hospital errs on the side of clinical propriety. The clinical staff would rather treat patients than risk their condition worsening. That is done despite the high costs of certain treatments—a point not mentioned by the noble Baroness in her opening speech—in particular those for HIV and TB where the drug costs are high. As the noble Baroness, Lady Howells, said, that is part of the tradition of the NHS, and it is a part of the tradition that I hope we will not lose. It would be shameful if we were to send away from our shores people who were in immediate danger or who had acute illnesses, whether or not they should have got here in the first place.
Is it the Government's intention to tighten up the performance of hospitals in monitoring the numbers of such patients, their cost to the hospital and the rate of recovery of debt? It will be difficult to legislate or to table regulations on a subject on which the Minister, when we discussed it in a Starred Question and I asked about the size of the problem, was clearly unable to respond. It would be unfortunate if the measures taken to redress the ills to which the noble Baroness referred in introducing the debate were out of proportion to the size of the problem. I hope the Government will reassure the House that in carrying forward this valuable review they will nevertheless have an eye to proportionality.
§ 3.40 p.m.
§ Earl Howe
My Lords, the noble Baroness, Lady Boothroyd, is to be congratulated on having introduced a debate which raises particularly interesting and sensitive issues which I suspect, if we were truthful, some of us who are believers in the National Health Service ethic would rather not have to confront. But I am glad that she has made us confront them because while the founding ideals of the NHS may not have changed since 1948, we cannot ignore the fact that the world around it has changed a very great deal. We live in a global society; and if an essential and very expensive service, which is entirely funded by the British taxpayer, is being offered and delivered to large numbers of people who do not live here, then we need to take a conscious decision: is this or is this not something we are prepared to live with?
I am sure that I am not the only person who found themselves in sympathy with both John Reid and John Hutton recently when each of them, on separate occasions, voiced their disquiet about abuse of the system and the need to protect taxpayers' money. The trouble is that none of us exactly knows how much taxpayers' money is being lost in this way. The published estimate of £50 million to £200 million is not one which the Government say they can sign up to. But that in itself highlights how unsatisfactory it is that we are debating this issue and have nothing more to go on than anecdotal evidence.
959 We read a lot in the press about health tourism. There are occasionally leaked reports, such as the one last year from Newham Hospital. A manager of one of the major hospitals in south London recently spoke out about "horror stories" happening all over the country, with her own hospital alone seeing 1,400 health tourists last year. A report last May by the Centre for Policy Studies suggested that some health tourists run up bills of over £50,000. In that report, one senior consultant estimated that 20 per cent of patients on his inner-city ward were asylum seekers, refugees and foreign nationals who were not entitled to NHS treatment.
If you talk to hospital doctors, they will tell you that there are three main categories of health tourists: those who come here to take advantage of childbirth facilities; those who need kidney dialysis; and those who come here looking for transplants of organs or bone marrow. The cost of treating a bone marrow transplant patient, I am told, can exceed £100,000. So if it is happening on a large scale we are indeed talking about significant sums.
Let us suppose that the total bill from health tourism is of the order of £200 million. I may be eccentric but, having had the privilege of serving in government, I cannot bring myself to dismiss this sort of expenditure in an airy fashion as de minimis. It is, in absolute terms, a large amount of money for us to be writing off.
But what is needed is some hard evidence. Until the scale of the problem has been measured reliably, I do not think that any government initiative to curb health tourism will he taken as seriously as perhaps it ought to be. There is a great deal of cynicism around. Health tourism is regarded by certain doctors as just a scare story which Ministers like to bring out of the cupboard when it is politically expedient to do so.
But I have to say that I am with Ministers on this one. Subject to one reservation, the proposed changes to the rules for charging overseas visitors for NHS care announced last month are, I think, perfectly reasonable. In fact, more than one of the changes would actually extend eligibility for free treatment to people who cannot get it at the moment. That is fine. My reservation relates to failed asylum seekers who, through no fault of their own, cannot be returned to their country of origin. There are quite a number of these people, particularly from countries in Africa. More thought needs to be given to this group, because many of us would feel very uncomfortable denying basic health to such people.
The only other element of controversy in the consultation exercise was in relation to primary care and whether the regulations should apply there as well. A press release from the Department of Health in December said that changes to the rules on primary care treatment would be announced in January, but, so far, I have not seen that announcement.
The main issue, though, is not so much what the regulations will contain as how they are to be policed. Doctors are quite firm about this: they do not want to 960 be policemen or surrogate immigration officials. I believe that that is entirely reasonable. They should not be asked to act in either of those capacities. But my worry is that nobody else will be acting in that role either. Overseas patient managers exist in each hospital but their job is primarily one of recovering costs from patients once they have been treated rather than questioning them on their arrival. The Government really need to focus on how to help these managers perform their inquisitorial role and how to help them become more effective in their debt recovery work.
It was very interesting hearing John Reid saying in January that foreigners who use the NHS will in future have to pay for their treatment in advance. That is quite a bold idea, but it is rather difficult to see how it could be brought into effect without significant extra work for doctors. Indeed, the Government's assertion that the rule changes will not involve any significant extra work for doctors is at odds with their admission that they cannot quantify the scale of the problem. I should be glad if the Minister could say something about this idea when he replies.
There are some who believe that the answer to all our prayers lies in the introduction of identity cards. Margaret Edwards, the NHS director of access, and Richard Douglas, the NHS director of finance, were reported as having written to John Hutton stating that ID cards were a sine qua non of any credible proposals to clamp down on health tourism. The implication here, as they were quoted as saying, is that we will need to wait until 2007 when ID cards are due to be phased in before we can start asking GPs to become gatekeepers on their patients' eligibility for free healthcare. Quite what GPs think about this idea I do not know. Aside from that, we need to be a little careful here. ID cards are likely to be given to British nationals, but eligibility for free healthcare on the NHS is based largely on whether an individual is ordinarily resident in the UK. Relying on ID cards would mean that, for example, British nationals not fulfilling the residence criteria would be able to claim free care when they are in fact disentitled. If we are to restrict access to the NHS by means of a card, we need a card that is dedicated to that purpose—in other words, a health entitlement card.
Health tourists are defined strictly as overseas visitors who unlawfully obtain free medical treatment. Most of us bridle at the thought that our health service is seen by some people abroad as a soft touch, and it is that kind of exploitation that I have been talking about up to now. But there is an extra dimension to the issue when we come to think about certain categories of people who are legally entitled to NHS care—namely, legitimate immigrants. The problem with these people is not that they are health tourists—for they are not—but that in many cases they present a serious public health risk, and their sheer numbers, if we are not careful, threaten to overwhelm the system.
961 Yesterday I paid a fascinating visit to the Health Protection Agency in Colindale which laid on a very interesting presentation on HIV/AIDS. By far the largest proportion of new cases of HIV/AIDS over the past six to seven years is attributable to immigrants from the continent of Africa. Last year's total was the highest ever at more than 7,000. A similar story can he told about TB. More than 50 per cent of TB in this country occurs in people born abroad, most of whom have arrived in the past ten years.
If we look at what is going to happen on 1 May, when the European Union gains 10 new member countries, we can see that many millions more individuals will suddenly become entitled to free NHS care. We do not know how many people will choose to enter the UK from the accession states. The Home Office estimates between 5,000 and 13,000 people; others think that the numbers will be much higher. However, we need to be aware that seven of the 10 accession countries have growth rates in HIV/ AIDS that are among the world's highest. A UN report published last month suggests that the disease will actually threaten development prospects in eastern Europe and the CIS. In Estonia, upwards of one out of every 100 adults is estimated to be carrying HIV, a threshold above which efforts to turn hack the epidemic have failed in many other countries. Most of those who carry the virus are aged between 15 and 40. They represent the hulk of the labour force and the age group most likely to seek employment prospects in more developed parts of the EU.
The UK is unusual in not requiring an HIV test prior to immigration. I wonder whether the time has not come to look again at the idea of screening. Perhaps the Minister would comment on that point. It is late, but hopefully not too late, to address what may become a significant call on NHS resources.
Our debate is not just about where the boundaries of the law should lie, but what our moral obligations are as a rich, developed nation; and what is practicable for us to try to do within existing NHS resources. We cannot bury our heads in the sand and hope for the hest. I hope that the Government will listen and that they will act, not simply in terms of new regulations, but also by offering answers to the practical questions that I and other noble Lords have raised today. Those questions are the ones that, in the end, really matter.
§ 3.52 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Lord Warner)
My Lords, I thank the noble Baroness, Lady Boothroyd, for her interest in this important subject and for her support for the action that the Government are taking. I know that it is a matter of great concern to her and other noble Lords that NHS money is spent on providing treatment only to those who are entitled to receive it free of charge and not to those who are not. I reassure your Lordships that that is no less important to Her Majesty's Government. That is why new amendments 962 to the existing regulations governing charges for hospital treatment will, subject to parliamentary approval, come into effect on 1 April. Those amendments are intended to achieve exactly what the noble Baroness and other noble Lords have requested; namely, the tightening-up of regulations so as to minimise the scope for abuse. I thank the noble Earl for his support for that approach.
Before I turn to eligibility for free NHS treatment, let me acknowledge the thoughtful words of my noble friend Lady Howells, in particular her figures for, and recognition of, how much the NHS owes, and will continue to owe, to people from overseas who work within the NHS at all levels. They pay their taxes and they help to run a service on which many of us rely.
The noble Baroness, Lady Thomas of Walliswood, drew attention to the complexity of the categories of overseas people in this country relating to when they may seek NHS treatment. It is a common misconception that entitlement to free NHS services is based on nationality, tax or national insurance contributions. That is not the case. Rather, it is based on whether someone is, as the noble Earl, Lord Howe, said, ordinarily resident in this country. Section 121 of the NHS Act 1977 gives the Secretary of State for Health powers to establish charges for NHS services provided to anyone who is not ordinarily resident in Great Britain. Those powers have been used in relation to hospital services by means of the NHS Charges to Overseas Visitors Regulations 1989. Those regulations define an overseas visitor as anyone who is not ordinarily resident in the UK. They also set out a range of exemptions from charges and clearly place the responsibility on the local NHS body providing treatment to establish whether any of the exemptions apply. That has always been the position; it is a responsibility held at the local level to collect the money where the exemptions do not apply.
There are two ways in which a patient can be eligible for free NHS treatment: either because he or she is ordinarily resident here or because, although an overseas visitor, he or she is nevertheless exempt from charges. It has long been the case that a national of a country other than the UK could be entitled to free NHS hospital treatment in certain circumstances.
We recognise that much has changed in the 15 years since the current charging regulations first came into effect. Patterns of employment, of migration and of lifestyle have changed. We realise that the charging regulations need to be brought up to date. That is why we have been reviewing the operation of the charging regime through discussion with frontline staff operating the system, and with clinicians and others directly involved. It has become clear that unintended loopholes have developed over time, and that action is needed to close them and return eligibility for free NHS hospital treatment to the "ordinarily resident" basis it was always intended to have.
Following a full public consultation last year, on 30 December my right honourable friend the Minister of State for Health announced changes to tighten up the charging regulations. Those changes will come into 963 effect on 1 April, subject to parliamentary approval, and will deal with the following abuses. First, it will deal with people who take advantage of their own exempt status to bring their families over for short visits just to obtain NHS hospital treatment, particularly in order to give birth. In future, they will need to show that the family are living here with the exempt person on a permanent basis. Secondly, it will deal with people who use the fact that they are coming here on a short-term business trip to get free hospital treatment. In future, they will need to be employed by a UK-based company. Thirdly, it will deal with people who have been living here for more than 12 months but are here illegally. The 12-months residency exemption will apply only to those who are living here legally. Fourthly, it will deal with people who live and work overseas, but think that they can just pop hack here for a few weeks to receive free NHS treatment whenever they feel like it. In future, anyone who has been working away for more than five years will not be entitled to free treatment unless they can show they are returning here to live permanently.
We are also moving to end the current confusion about the status of overseas students by introducing a specific exemption for them, and to make life easier for British pensioners who choose to spend part of the year living in warmer parts of Europe.
The charging regulations apply only to hospital treatment. As the noble Lord, Lord Rea, said, the situation is different for services provided by general practitioners. Primary care trusts have a duty to ensure that arrangements are in place to provide primary medical services for all persons in their area. There is no residency or nationality requirement. For their part, GPs have discretion as to whether they accept any application to join their patient list, including from overseas visitors. If a GP accepts an individual on to the list, he or she is then obliged to provide services free of charge. The Government expect GPs to exercise their discretion with sensitivity and with due regard for the circumstances of each case. Regulations allow persons who are in an area for short periods to register with a GP as a temporary resident. Existing guidance steers GPs towards accepting overseas visitors as NHS patients, if at all, as temporary residents.
However, we believe that the time is now right to look at this matter afresh. On 30 December, my right honourable friend the Minister of State, John Hutton, confirmed that we would shortly be outlining proposals for aligning primary care with the hospital charging arrangements. No decisions have yet been taken and any proposals for change will be subject to consultation.
I know that the noble Baroness, Lady Boothroyd, has been particularly concerned about reports that large numbers of overseas visitors obtain free maternity care for which they are perceived to be ineligible. Our review of the charging regime has made it clear that that is indeed a significant issue for some parts of the NHS. However, I again emphasise that under the current arrangements not everyone is ineligible just because they are from overseas. There 964 are a number of exemption categories that can apply to pregnant women, so they are doing nothing wrong. Nevertheless, we recognise that this is a problem and we have been taking steps to tackle it. As I have already mentioned, we are changing the charging regulations to close the visiting relatives loophole. This will mean that charge-exempt overseas visitors will no longer be able to bring their wives here for a carefully timed visit to ensure that they are here at the time of their confinements. Rather, they will have to show that their wives are actually living permanently with them in the UK before their exemption can be extended to them.
However, there is also a problem with women being able to get into this country in the very late stages of pregnancy. Officials have had discussions with British Airways and the Board of Airline Representatives in the UK to talk about what steps might be taken to improve matters. In fact, most airlines have policies on carrying women in late pregnancy, but there is some evidence that not all airlines are as thorough as they could be in applying them.
As a result of those discussions, British Airways has reissued its guidance to all its check-in staff, and BAR UK has undertaken to remind all its members of the importance of adhering to whatever carriage policies they have in place and, in particular, to IATA guidelines on this. This reminder was issued last month.
However, no matter what steps we take, there will still be women who manage to get here and just turn up in an accident and emergency department actually in labour. I am sure that noble Lords will agree that in such cases the NHS has no choice but to provide the necessary maternity care to avoid risks to mother and baby. As I have said before in this House, and will say again and again if necessary, the NHS is at its heart a humanitarian service. I am sure that all noble Lords recognise that in these circumstances we are dealing with the lives of children about to be born. Nevertheless, we are clear that, even in such cases, if the patient is chargeable, that charge must be levied and pursued as far as is reasonable.
Concern has also been expressed about imported infections and immigration. This country, like others, is affected by the global epidemiology of infectious diseases. There is no difference between the noble Earl, Earl Howe, and me on that. That is why the Cabinet Office is currently leading a cross-departmental review of imported infections and immigration. The review aims to establish the facts about the impact of immigration on public health and NHS expenditure. It is considering all relevant issues, including health screening, and will propose solutions should action be required. The review is continuing and no decisions have yet been taken, so I cannot say any more at this stage. However, I can say that I recently made a presentation about HIV/AIDS policies in this country to an EU meeting. In the course of that, I heard the concerns that were being expressed by health ministers from CIS countries and eastern Europe.
965 However, we must not forget that we have an imperative duty to protect public health. That is why the treatment of certain communicable diseases, such as tuberculosis, is free of charge to all, irrespective of their status. It is far more important that we limit the spread of such diseases by early diagnosis and comprehensive treatment than that we risk putting people off coming forward for treatment by requiring them to pay for it.
The situation is not, however, quite the same where HIV/AIDS is concerned. Here the main risk to public health is from onward transmission by people who do not yet know that they are infected. HIV is not communicable via the airborne route in the same way that TB and other diseases are. The most important issue, therefore, from a public health perspective, is to encourage the early diagnosis of HIV so that patients can be advised on the steps they need to take to protect themselves and others. It is for that reason that diagnostic testing for HIV and the associated counselling is free of charge to all, irrespective of their status. However, treatment of HIV is complex, does not provide a cure and is therefore lifelong. There is not, as a result, the same justification for providing treatment of HIV free of charge to all, which is why it is chargeable unless the patient is otherwise exempt.
I turn now to the arguments that the NHS will be swamped after the 10 accession countries join the EU. We already have reciprocal health agreements with six of the 10 EU accession states which allow for treatment to be provided on exactly the same basis as their residents will be entitled to once they are part of the EU. So we are talking about a new entitlement in relation to only four countries. Visitors who access NHS services for emergency or planned care are paid for by their home countries, so no net cost is involved in relation to the NHS. If working here and ordinarily resident, they are entitled to NHS care; but they are also paying taxes. As an aside, I should say that one or two places in this country would not mind being swamped with Polish dentists if that would help with some of their local services.
Noble Lords raised the issue of whether money was adequately provided at the local level to cope with areas with a large intake of people from overseas. As we have said many times, primary care trusts decide local priorities regarding their local community needs. They distribute 75 per cent of NHS resources, and these resources are increasing by 7.5 per cent annually in real terms over a five-year period. This provides a fair degree of leeway for people to cope with changing circumstances in their local communities.
I should like to reassure my noble friend Lord Rea on some of the issues he raised, one or two of which were raised also by the noble Earl. On continuing care for failed asylum seekers, the Minister of State's announcement on 30 December made it clear that treatment already underway when it is decided that someone is here unlawfully will continue no matter how long the patient may have been here. We have never suggested either that doctors will have to police the system; that is the role of the overseas visitors manager. I shall return to that in a few moments.
966 I know it has been suggested that the NHS does not bother to enforce the charging regulations. I think that that is unfair to overseas visitors managers who put a huge amount of time and energy into identifying and pursuing payment from overseas visitors, and are very successful in doing so. I am grateful to the noble Baroness, Lady Thomas of Walliswood, for acknowledging that that was the case in her area.
Of course, there are other NHS trusts where the regulations are not so strictly enforced because of staff pressures, or because the regulations themselves may have fallen somewhat into disrepute. However, we must hold on to the fact that it is down to the people at the local level to have systems in place that enable them to obtain information about people who are not exempt from charges and ought to be paying, and to collect those resources for their local health service's need. They are in fact letting down people at the local level if they do not put those systems in place.
To reassure the noble Baroness, Lady Thomas, I can say that when the amended regulations are in place we will be carrying out a major programme within the NHS to raise the profile of the overseas visitors managers and to ensure that NHS bodies, particularly trust chief executives, understand that the regulations place obligations on them which they must fulfil and in which, no doubt, their auditors will take an interest. NHS trusts do not actually have a choice in charging overseas visitors; the regulations require them to do so, and there is a task for the Department of Health in making sure that that is properly understood. We will also be revising all our patient literature for overseas visitors, to help NHS trusts in getting the message across to overseas visitors that they should expect to have to pay for hospital treatment.
Before concluding, I should like very briefly to say a few words on the figures that have been bandied about in the press about so-called health tourism. My right honourable friends the Secretary of State and the Minister of State have both said publicly that we do not know how much money is being spent on chargeable overseas visitors. We know anecdotally that the NHS tells us that this can be significant in some—I emphasise "some"—of our bigger inner city trusts and those near airports and major entry points to the UK. We have to be proportionate, however, in the way that we demand information from people at the local level. We are shifting the balance of power in that area regarding people's responsibility to collect that information.
In conclusion, I hope that what I have said will help to reassure noble Lords and in particular the noble Baroness, Lady Boothroyd, that the Government take very seriously indeed the issue of overseas visitors abusing the NHS and are taking a range of steps to deal with it. I do not pretend that the changes we are making to the regulations will resolve all the problems overnight, nor will we ever get to a situation where the NHS never has to treat someone in need who should pay but does not have the means to do so. There will always be hard cases where the NHS has to put the needs of a seriously ill patient before whether or not they can pay. It is always important to bear in mind 967 our healthcare obligations to asylum seekers under international law, our obligations to our fellow members of the EU, including the 10 new accession countries, and with the 30 or so countries with whom we have reciprocal healthcare agreements, and which benefit UK visitors to those countries if they fall ill.
Those obligations mean that there will always be—as there has been in the past—a proportion of overseas visitors who are not ordinarily resident but who are taken ill while they are here and receive healthcare to meet their needs and our international obligations. Those people are visitors in need, not health tourists.
968 Nevertheless, I am convinced that, given time, the changes we are proposing to the charging arrangements will make a real difference and improve public confidence.