National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2017

Baroness Taylor of Bolton Excerpts

Thursday 16th November 2017 Lords Chamber

[Baroness Redfern (Con)]

My Lords, I refer to my entry in the register of interests. The regret Motion at first appears to imply that charging overseas visitors is something new. The requirement for the NHS to charge overseas visitors has been in place for 35 years—but, unfortunately, compliance and recovery rates have historically been extremely low.

I thank the NHS workforce for the fantastic job that they do; they are now treating levels of demand not seen before. Do noble Lords not think it only fair that any overseas visitor using our NHS should make a financial contribution, just as we all do when we are on holiday abroad and possibly want to access medical help?

It is important to emphasise that NHS England, NHS Improvement and the department have published guidance to support the embedding of the regulations, producing an average price list so as to better inform and enable patients to look at the up-front charges for anyone not eligible for free NHS care. Those people can then make informed choices about their care here or at home.

I am informed that, in order to protect the most vulnerable and to protect public health, the department remains committed to ensuring that vulnerable groups are always able to receive free care and that no patient will be denied urgent or immediate healthcare, regardless of their immigration status or ability to pay. This includes all maternity care in every setting, including diagnostic, and the treatment of infectious diseases.

Back in July, the department introduced new regulations to support improved cost recovery and make it fairer and more efficient for both the patient and the healthcare system. It saw recovery increase from £89 million to £360 million—all being transferred back into our front-line services.

Finally, with careful monitoring and ongoing assessments and with better use of existing data sources to improve efficiency, we will be able to see for ourselves the financial effectiveness and value for money through this process. These figures will be published in the new year.

[Baroness Taylor of Bolton (Lab)]

My Lords, I first congratulate my noble friend Lord Hunt on initiating this debate. Like him—and other speakers—I acknowledge that the NHS is under significant pressure and that there have been charges for a very long time. However, I say to the noble Baroness, Lady Redfern, that, if there is a problem with cost recovery, these regulations are not the answer.

I am prompted to intervene in this debate because of an organisation in Bolton, my home town: a local group called City of Sanctuary. Its role is to create a culture of welcome and safety for refugees and asylum seekers. As a Member of the other House, I had a considerable amount of casework dealing with refugees, asylum seekers and failed asylum seekers, so I know that its work is extremely important and that it has a great deal of direct experience. It has raised concerns about vulnerable groups, particularly those I have mentioned. I note that this category is not mentioned by the Minister in his letter.

There are three points I want to raise. I have read the Minister’s letter to all Members with care and I thank him for it. He tries to be reassuring, but I am afraid that he does not allay all the concerns that some of us have on the basis of the evidence that has been presented to us.

The Minister says that the regulations require that up-front charging for non-urgent or immediately necessary care will become a legal requirement. That is the basis of these regulations. But there is an immediate problem with the definition of “non-urgent” or “needing immediate care”. I think particularly of those people, such as refugees and others, whose full medical history is not known, may not be available or may not be fully evident, or who may not have proper cognisance of it themselves. It can be a very real problem, I suggest, for both the patient and the doctor. The medical groups who have expressed concern about this have made a very strong case.

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We have also been careful to exempt from charging the diagnosis and treatment of specific infections that could put the health of the wider public at risk. This includes infectious diseases—which was raised tonight—such as pandemic flu and sexually transmitted infections. Finally, no one will be charged for primary medical care, which includes GP care, even if it is received outside a practice.

[Baroness Taylor of Bolton]

In the list the Minister gave, he did not deal with the point that the noble Baroness, Lady Hamwee, and I raised about failed asylum seekers who are still living in England.

[Lord O’Shaughnessy]

For clarity, they are not covered under the exemptions.

The second change the amendments make is to the requirement that any care not deemed immediately necessary or urgent by a clinician is paid for up front. The published guidance, again, for nearly 30 years, has recommended this. This practice ensures that a chargeable patient can make an informed choice about their care and therefore does not unwittingly incur debts when they could instead, for example, choose to wait for treatment until they have travelled home. Given that our NHS is facing unprecedented levels of demand, I hope noble Lords will agree that mandating this position is a sensible approach and that it will help make sure that all users of the NHS make an equitable contribution to ensure its continued success and viability.

The noble Lord, Lord Hunt, has asked whether this practice will not create barriers between vulnerable patients and treatment and result in racial profiling as the front line seeks to determine eligibility for free care. I have already drawn noble Lords’ attention to the exemptions in place and the fact that all GP and A&E services remain free for all. I am also clear that immediately necessary or urgent treatment—such as all maternity services—will never be withheld, regardless of the patient’s ability or desire to identify themselves or pay. To reassure the noble Baroness, Lady Taylor, and other noble Lords, it is for clinicians, and no one else, to determine whether a treatment is immediately necessary or urgent.

On whether patients may face discrimination, this is always unacceptable and not compliant with anti-discrimination legislation. As my noble friend Lord Leigh pointed out, our guidance is clear that simple, short questions should be asked by trained staff of all patients whose records do not already indicate residency status to assist in identifying those not eligible for free care. That information can then be captured in the patient record for the future.

To support the implementation of these regulations, we have developed with front-line staff a “cost recovery toolbox” containing extensive guidance and template letters to patients and clinicians, as well as patient and staff-facing leaflets and posters and a web-based forum for peer support. As my noble friend Lady Redfern pointed out, working with NHS England and NHS Improvement, the department has published operational guidance to support the introduction of the regulations. This includes an average price list to provide consistency in up-front charging. The department has recruited a senior, experienced cost recovery team of NHS professionals who have led improvement visits to over 20 NHS trusts over the last six months. Action plans are in place for each trust and the team will support improvement and the sharing of best practice across the wider NHS.

I would like to end on an issue which has been raised by many noble Lords in this debate: the assessment carried out before we introduced these changes. As I have explained, up-front charging did not represent a change in policy, but instead has existed for many years before the consultation on other amendments. Over the course of the consultation and decision-making process, the Government carefully considered the impact the charges may have and published a full impact assessment alongside the regulations. This concluded that the package of changes would identify up to £40 million a year for the NHS. This is additional income and takes into account any administrative costs associated with the changes. I will also place in the Library copies of the equality assessments carried out by my department to inform the regulations, so that Members of the House will be able to review how the impact on vulnerable and protected groups was very carefully considered prior to the introduction of these changes.

All noble Lords have asked about the implementation of these changes and it is right, of course, that we proceed cautiously and sensibly and that we review how we are doing. So I am very aware of the need to keep the impact of these regulations under careful review in order to make sure they are implemented as planned and with no unintended consequences. My department will therefore undertake a full, formal review of how these amendment regulations are implemented, and monitor delivery closely, particularly where healthcare is provided to the most vulnerable. If further action is needed I will commit to update the House accordingly.

I hope I have been able to reassure all Members of this House about the long-standing principles that underpin our approach to cost recovery, the care that has been taken to protect vulnerable groups, and the reflective approach we will take during the implementation of these policy changes. I believe that they provide an equitable and reasonable step forward in making sure that all the NHS’s users, wherever they come from, make a fair contribution to the sustainability of the NHS, which is what British citizens expect. On that basis, I ask the noble Lord, Lord Hunt, to withdraw his Motion.