Expert groups criticise access to health care proposals, but will the government listen?
In summary, the government aims to:
- Introduce a health levy that migrants without permanent residence would have to pay when applying for a visa in order to be able to access NHS services.
- Extend charging visitors and irregular migrants for NHS treatment to primary care, including seeing a GP and potentially to emergency care.
- Introducing a new registration and data sharing system to enable the NHS to identify and charge patients.
A fuller briefing on the proposals can be found here.
The main representative medical professional associations, including the British Medical Association, the Royal College of General Practitioners and the Royal College of Midwives have made submissions strongly opposing the proposals. So have important charities working on specific medical issues such HIV and maternity, different trade unions and lawyers’ groups. Experts in all these fields have highlighted significant misgivings about the proposals including major uncertainties and potential negative impacts.
Normally you would expect government to listen to serious concerns on the part of experts and to adapt their proposals to respond to those concerns. That is what public consultations should be about after all. We hope this will be the case with the proposals on access to health. However, when it comes to policies towards migrants the political stakes are too high and measures seem to be designed to look tough rather than to ensure better services and outcomes to the whole population.
One major criticism is that the Department of Health only currently carrying out an audit of the cost to the NHS of overseas visitors, which means that the audit did not inform the proposals before they went to consultation and that the evidence supporting them is quite weak. There have also been rumors that the Immigration Bill, which will create the statutory framework for some of the health proposals, is to be published in the next two weeks, very likely before a government response to the consultation. So here we have a consultation where the evidence has not yet been produced and where the key policy instrument it is supposed to influence will probably be published before the government analyses submissions. Nevertheless, one would hope that government will take heed of the opinions of health and law experts on key aspects of the proposals.
Objections seem to fall into several groups:
The nature of the NHS
The proposals undermine the principles on which the NHS is founded: namely a comprehensive health system that is free at the point of access and ensures healthcare to all in need. The RCGP has said that the proposals will ‘be a regressive step for the NHS and would undermine the ability of GPs to protect and promote the health of their patients and the public.’
The proposals will produce negative health impacts on individuals who may be prevented from accessing healthcare and more generally on the whole population as there is an increased risk to public health. The RCGP has stated that ‘limiting free access to primary care will have adverse consequences for the control of infectious diseases – and therefore for the health of the population as a whole’. The National Aids Trust response argues that ‘any practical or perceived barriers to primary care (GP) access for migrant communities in England will undermine efforts to reduce undiagnosed HIV in this group. This will in turn undermine the protective impact of universal HIV treatment for these individuals, their communities and the wider public.’
The proposals will create a burden on health professionals and patients who will need to undertake additional administrative processes to check eligibility for free care. The BMA has said that the proposals will ‘lead to the NHS access status of every patient being checked by GP practices on registration, leading to inconvenience for all patients’ while the RCGP has stated that they ‘struggle to see how a new system for checking eligibility - and potentially charging patients - could be introduced without increasing the administrative pressure on individual GP practices.’
The Immigration Law Practitioners’ Association has highlighted key difficulties on relying on Home Office information to determine eligibility: ‘if health records are to draw on Home Office records, they will be infected with the same problems as are Home Office records. The fourth data protection principle requires those making use of personal data to ensure that it is accurate and up-to date and the Department of Health will thus leave itself open to challenge.’
The proposals are unlikely to generate any significant savings to the NHS and may end up costing more than they save. The RCGP has said that ‘a change in the eligibility rules for general practice would deter early presentation in general practice by a significant number of patients, which may lead to a costly increase in emergency admissions (additional pressure that the urgent and emergency care system can ill afford).’ Managing a registration system could also lead to costly systems and contracts with private contractors. ILPA’ response highlighted that ‘officials find it very difficult to manage these contracts effectively. Just as poor management of support contracts places a burden on local authorities so poor management of any registration contract would place a burden on front-line National Health Service staff.’
Practicalities and evidence base
The proposals have not been thought through. There is very little detail on how they will be implemented and therefore how intrusive or practical they may be. The BMA has stated that ‘the lack of a detailed accompanying equalities impact assessment, or an impact assessment detailing the money that it is intended to save and the potential costs, is a major concern’ and the RCGP has expressed that they ‘are extremely concerned that these policy proposals are neither accompanied by an impact assessment nor underpinned by robust evidence’ and that ‘the policy proposals under consultation have been developed in advance of the supporting evidence’.
Many of the changes to implement the proposals will happen through secondary legislation and rules and therefore will not be subject to extensive debate in Parliament. However, some of the changes (the levy on temporary migrants and re-defining ‘ordinary residence’) are likely to be part of the Immigration Bills, providing an opportunity for MPs and Lords to debate some of these issues.
These proposals will have a massive impact on migrants, especially on those with irregular status who are destitute. They form part of a host of measures designed to create a ‘hostile environment’ for undocumented migrants. If they go ahead, they will certainly succeed in making life more miserable for those in that situation.
There should be no doubt, however, that this suite of proposals will also impact migrants who are in the UK lawfully and everybody who is a resident as well. The cost of limiting access to ‘illegal’ migrants is likely to be more costs for the NHS, a complicated and burdensome administrative system for all patients and poorer health outcomes for all, including undermining public health initiatives. This is the view of experts and government as well as MPs voting on them should listen carefully.