NHS (Foreign Nationals)

Chris Skidmore Excerpts

Tuesday 22nd May 2012 Westminster Hall

[Chris Skidmore (Kingswood) (Con)]

Thank you, Mr Streeter, for calling me to speak. It is an honour to serve under your chairmanship.

I very much appreciate having the opportunity to speak on the issue of foreign nationals’ use of the NHS today. I know that it is of concern to all Members of the House, regardless of political party, because for many of us it is a huge issue for our constituents, who are genuinely concerned about the NHS, which is free at the point of use.

Obviously, the constituents I speak to accept that we should never turn away at the door anybody who is in genuine need, whether they are asylum seekers or not. Obviously, there are big public health issues and I welcome the fact that the Government have extended HIV treatment to those people in need regardless of nationality, because that will benefit the whole of our society. However, we cannot get away from the fact that there is a large issue, and one that is growing, regarding the use of NHS facilities by foreign nationals who are ineligible for free care.

As a member of the Health Committee, I am particularly concerned about this issue and I have put down several parliamentary questions, dating back to last year. The Government responded that roughly £35 million had been written off by hospital trusts, in terms of debts that had been accrued by foreign nationals and that had neither been paid back nor claimed back. The trusts involved did not include foundation trusts, so I made a freedom of information request of all trusts across the country. The data that I received back from the 118 NHS trusts that replied to me showed that just over £40 million of debt accrued by foreign nationals had been written off.

Those data also showed that there is a huge variation in relation to the collection of debt accrued by foreign nationals. The highest figure for such debt was for Guy’s and St Thomas’ NHS Foundation Trust, which had written off almost £6 million of such debt since 2004. My own local trust, North Bristol NHS Trust, had written off £1.7 million of such debt. The data showed that some trusts were acting contrary to the regulations and the current guidance, which

“place a legal obligation on the trust providing treatment to identify those patients who are not ordinarily resident in the United Kingdom; establish if they are exempt from charges by virtue of the Charging Regulations; and, if they are not exempt, make and recover a charge from them to cover the full cost of their treatment.”

That is what trusts should be doing when foreign nationals who are ineligible for free care come through their doors. However, it was clear from the information that I received in response to my FOI request that many trusts were not even collecting those data, which is contrary to the guidance. Of those trusts that were collecting the data, some had gone back to 2000 to collect them and some had gone back to 2004. There was a large variation in the data that cannot simply be explained by the fact that some trusts were more willing than others to claim back the debt that they were owed from foreign nationals.

There is anecdotal evidence, too. I have heard from some Members who wanted to be in Westminster Hall today for this debate but were unable to make it, and they asked me to raise some issues. In particular, one MP had a constituent who had come to them regarding an American visitor who was staying with them. During their holiday, the American visitor became ill and attended NHS facilities for treatment. They then contacted their medical insurer in the US, which suggested that they provide proof of the cost of their treatment; the American visitor would need a receipt from the NHS, so that they could claim back the money from their medical insurer. However, when they contacted the trust in question, they were told that no such receipt was available and the trust itself had not collected the data about the nature and cost of their treatment, even though this visitor was a foreign national and ineligible for free NHS care, and actually wanted to pay the bill because they were very grateful for the fantastic treatment that they had received. Consequently, a receipt could not be provided.

So there are examples of how trusts are clearly not following the guidance and collecting NHS debt from foreign nationals. It is particularly worrying that a 2008 survey of NHS managers suggested that a third of them did not even bother to ask patients whether they were eligible for free treatment when they arrived at hospital.

[Mr Virendra Sharma (Ealing, Southall) (Lab)]

Is the hon. Gentleman now talking about those foreign nationals who arrive here specifically to receive treatment, or those foreign nationals who come here as visitors, become ill and are then unable—for whatever reason—to pay for their treatment? We must not mix the foreign nationals with political asylum seekers, overstayers and others who, for whatever reason, live here for many years but are not eligible to receive NHS treatment. Is the hon. Gentleman mixing those two groups, or separating them?

[Chris Skidmore]

No, I am certainly not mixing them and I will come to the issue of eligibility that is defined around the term “ordinarily resident”. I want to talk about that in terms of the historic issues that determine whether foreign nationals should be charged for treatment. Obviously, there have been various reports in the past decade, including a 2007 report by the Joint Committee on Human Rights that examined services available to asylum seekers, and those reports have raised that very issue. If access to care and treatment was denied to those who are vulnerable and in genuine need of care, that would undeniably make the situation worse and cause them far greater distress and harm. In those circumstances, we have a right and a moral duty to ensure that people are treated.

On the other hand, we have what some red-top newspapers might call “health tourism”. I use that phrase with some trepidation, because the situation is certainly more complicated than that phrase implies; it suggests that people are simply flooding in across our borders to ensure that they can receive NHS treatment, and that is certainly not the case. There are eligibility criteria that apply, but my concern is that they are not being applied strictly enough by various trusts. On the back of the previous Government’s consultation on this issue, between February and June 2010, the current Government have now decided to tighten certain eligibility criteria, particularly regarding asylum seekers and specifically when asylum seekers have their right of asylum refused.

There is obviously an issue with border security as well, and I welcome the fact that the Government have introduced measures, through the Home Office, in relation to those who have left the country with unpaid debts to the NHS of more than £1,000. I put down a written question that suggested that each year there are 3,600 foreign nationals who accrue such a debt for their NHS treatment and that they should not be allowed re-entry to this country unless those debts were paid off. There is a spectrum through which one has to view who is a foreign national and who is “ordinarily resident”.

I do not deny that establishing the difference between those two groups can be very difficult and that there is a very fine balance to strike. Nevertheless, it is clear from the data that I have received in response to my FOI request that the current system is not working. If there is a situation, as there is at the moment, whereby debts are being accrued and not reclaimed, and whereby a third of NHS managers are not even asking patients whether they are eligible for free treatment or whether they are a foreign national, that is a very big issue.

In many ways, one can understand why someone working within an NHS trust would not want to ask someone about their nationality; it might simply be easier to provide treatment. That is because of the simple fact that, once someone has been categorised as a foreign national and therefore they must be charged because they are ineligible for free care, those charges must be recouped. The costs of recouping those charges could far outweigh the charges themselves.

Moreover, I do not deny that some patients will turn up at an accident and emergency department or trust with a particular complication, which becomes severely worse. For whatever reason, they happen to die and there is no way in which the charges for which they would have been liable can be recouped. All those particular situations need to be taken into account.

In the Health Committee, we looked at how different trusts operate and collect their debts, or even monitor which people coming through their doors are eligible for free care and treatment. West Middlesex University hospital has what is called a “stabilised discharge system”. If a foreign national is admitted to hospital, the doctor first establishes whether there is a need for urgent life-saving treatment, which is obviously a priority for the NHS. If that is not the case, the person is told what treatment is required and how much it costs. If they are unwilling to pay, they are asked to leave. That policy in the hospital nearest Heathrow airport has saved the hospital £700,000 in each separate year. Even within the existing guidance and criteria, there are the means and possibilities by which trusts can ensure that the criteria are followed correctly and that savings can be made. I am sure that if every trust acted in the same way as the West Middlesex University hospital, we would see the amount of debts incurred by foreign nationals drop significantly.

The hon. Member for Ealing, Southall (Mr Sharma) mentioned the criteria around a foreign national and who is and is not eligible for care. The context of this debate, as I mentioned, is an historic one. It was not until 1989 that the British Government began to require certain overseas visitors to pay for hospital treatment. That was defined in regulations in 1977, when legislation permitting persons not ordinarily resident in the United Kingdom to be charged for NHS services began to be looked at.

How we define someone who is not ordinarily resident, as opposed to someone who is ordinarily resident, is interesting. In a way, it is a common law concept, but in NHS health care legislation there is no definition of “ordinarily resident”. The only definition comes from a 1982 judgment in the House of Lords, which was actually in the context of the Education Bill that was passing through the other place at the time. The definition of “ordinarily resident” was:

“living lawfully in the United Kingdom voluntarily and for settled purposes as part of the regular order of their life for the time being, whether they have an identifiable purpose for their residence here and whether that purpose has a sufficient degree of continuity to be properly described as ‘settled’ ”.

That means that UK citizenship and past or present payments of UK taxes or national insurance contributions, contrary to what many of our constituents might think, are not directly taken into account in the way that “ordinarily resident” has been defined.

In the review that they are currently conducting, I urge the Government to consider how we will define “ordinarily resident” in future. The NHS is a contributory system that people pay into to receive free care at the point of treatment. That is right. The NHS is free for citizens who have paid into the system. It cannot be a free-for-all for everybody to use. Our constituents wish us, as legislators, to address that concern.

It is clear that the current rules and regulations, having been addressed and re-addressed over time, have caused some confusion. In 2007, the Joint Committee on Human Rights produced a report on services to asylum seekers. It suggested that the new rules introduced in 2004 regarding asylum seekers and whether they were eligible for free care—or, once their asylum application had been turned down, whether they were still eligible for free care—caused confusion about entitlement. It suggested that the interpretation of the rules appeared to be inconsistent, and that in some cases people who were entitled to free treatment had been charged in error.

At the time, the Labour Government began a consultation looking at the use of primary care by foreign nationals using the NHS. It is clear that in acute and secondary care, charging regulations apply. The problem is that the implementation of those charging regulations has not been effective, and we need to be more stringent about the implementation of current guidance.

Currently, there are no charges for primary care, whether people are eligible or not. People can register with a GP for primary care, regardless of status. The Labour Minister at the time, in 2004, held a consultation on whether there should be charges for foreign nationals and people who were ineligible for free care. He suggested that the consultation was necessary because

“the rules about entitlement to primary care are best described as a muddle.”

I agree. In my own experience as MP for Kingswood, I have found a firm of lawyers in Bristol—Deighton Pierce Glynn—that has been writing to doctors urging them to register patients and saying that if they do not, it will take legal action, regardless of the patients’ nationality and eligibility for free care. I raised the matter in the local media, in the Bristol Evening Post. It is wrong, and I am concerned that our NHS will become a legal paradise for lawyers piggy-backing on doctors who are doing the best that they can with the resources that they have. They know that NHS resources are stretched and need to be rationed and that there is a big problem.

One lawyer responded in the Bristol Evening Post by saying that lawyers were not trying to change the law:

“We are trying to apply the law as it is. Nobody is excluded from GP treatment. It is very clear. Hospital treatment is different. People come to us when they have been refused registration with a GP. There is nothing in the law that permits them to do that. Refusing them isn’t lawful.”

This particular case concerned asylum seekers who had had their asylum applications refused. When the GP in question received the letter from Deighton Pierce Glynn, an unnamed member of staff said:

“Someone at the PCT read the letter and panicked. Do we just register everyone who is illegal?”

There is clearly confusion being stoked by certain members of the legal profession who seem to be taking advantage of the uncertainty of eligibility within primary care so that they can profit when their clients wish to apply to the NHS.

On the situation in primary care, I was interested in a question asked by the right hon. Member for Birkenhead (Mr Field) on 23 April 2012. He asked the Secretary of State for Health

“(1) what documentation a foreign national who seeks to register with a GP is required to provide;

(2) whether a foreign national on a six month visitor's visa is entitled to register with a GP;

(3) on what grounds a GP whose list has not been closed may refuse an application to register from a foreign national.”

The reply was:

“Under the terms of their existing contract, general practitioners (GPs) have discretion in accepting applications to join their lists. However, they cannot turn down an applicant on discriminatory grounds. They can only turn down an application if the primary care trust has agreed that they can close their list to new patients or if they have other reasonable non-discriminatory grounds.

There is no formal requirement to provide documentation when registering with a GP. However, many GPs, when considering applications, request proof of identity and confirmation of address, but in doing so they must not act in a discriminatory way.

A decision on whether to register a foreign national who has a six-month visitor visa is therefore currently for the GP to consider.”—[Official Report, 23 April 2012; Vol. 543, c. 701-02W.]

That raises issues. I do not like to quote Sir Andrew Green, the chairman of Migration Watch UK, but he stated:

“What this means is that someone getting off a plane with a valid visitor’s visa is, in effect, able to access the GP services of the NHS without ever having paid a penny into the system. Over one and a half million such visas were issued last year.”

Once someone is registered with a GP, the regulation and guidance mean that if they need further secondary care, it is the relevant NHS body’s duty and not the GP’s to establish the requirement for free hospital treatment. That raises the issue of the extent to which that takes place. Once someone is on the GP’s books, that is almost a rubber stamp into receiving secondary care.

I am not suggesting that GPs act as pseudo-immigration officials checking people’s eligibility for free care, but there clearly needs to be a more joined-up approach between the people who end up on GPs’ books and who are then referred by GPs to secondary care specialists, and what that then involves in terms of charging. When it comes to the issue of primary care and foreign nationals, I do not believe that foreign nationals should be entitled to free primary care. We should extend the charging regulations further.

[Mr Virendra Sharma]

I apologise; I should have congratulated the hon. Gentleman earlier on securing this debate, which is important not only to his constituents but to people all over the country, who take the issue seriously. It is also important in my constituency, where it is discussed every day.

I am a bit confused; I hope that the hon. Gentleman will clarify. He is mixing foreign nationals and those who have been here for many years. As I see it, in this debate, foreign nationals are those who come especially to register themselves for a few days, who receive treatment and who disappear without paying, due to system failures, although I will not get into that debate. For those already here, if GPs act as immigration officers or work on behalf of the UK Border Agency, that will mean health problems.

[Mr Gary Streeter (in the Chair)]

Order. Interventions should be brief.

[Chris Skidmore]

I certainly do not mean to confuse or mislead. When I say foreign nationals, I mean those who come to this country requiring care who are not defined as ordinarily resident under the current regulations. Personally, I think that we should consider the definition of “ordinarily resident”. I have no problem with people’s nationality, whether they are British or a citizen of whatever country. If they work in this country and are contributing to society, it is right that they should receive the free care towards which they have contributed.

Equally, exemptions apply for matters of public health and vulnerable groups. As the hon. Gentleman mentioned, if denying access to treatment could worsen the health of the community, let alone the individual, it is right that we should act responsibly. However, that should not preclude the creation of a clear definition of who is and is not eligible for care. One reason why we are having this exchange is that there is no clear, black and white definition. There will, obviously, be shades of grey, as there always are in health care. Health care professionals have a moral obligation to treat people in need, the sick and the vulnerable. I do not deny that, but we also have a moral obligation to our taxpayers to ensure that NHS money is spent as well as it can be.

A few people have come to me and said, “Mr Skidmore, it’s only £60 million out of a budget of £110 billion. Surely you’ve got to factor in debt. We should be able to expect that amount of debt to be written off.” I do not accept that argument. My local community hospital, Cossham hospital, is undergoing a £20 million refurbishment at the moment, and my constituents are so excited that it is taking place. That £60 million is a lot of money; it could have paid for the refurbishment of Cossham hospital three times over. We must count millions in order to save billions. During this efficiency drive, when we are trying to reinvest 15% to 20% of NHS resources in front-line care, it is a key aspect of the Nicholson challenge that we look for waste in the system and for instances where regulations are not being applied effectively.

I agree with the hon. Gentleman that we must be careful about how we define a foreign national. I do not want this to be seen as a xenophobic campaign, because it certainly is not. It is based on the conviction that the NHS is a national health service that provides free care at the point of use, but should not be abused; it should be free at the point of use, but not at the point of abuse.

The GP situation includes the lawyers at Deighton Pierce Glynn, who have been contacting GPs, and the Minister of State’s answer to the right hon. Member for Birkenhead about the issue of visas and documentation, which raises an issue that I think GPs would welcome.

Part of the consultation involves clarity about what GPs must look for when patients register in their practices, and whether they can say, “I’m afraid I cannot register you, because you don’t have the necessary data documentation.” As far as I understand it, the lawyers have been writing to GPs saying that by not registering patients, they are applying a discriminatory process. However, I was interested to read that paragraph 5.16 of the guidance on charging, in the section on GPs in primary care, says:

“It is important to see that all patients are treated the same way, to avoid allegations of discrimination.”

That is also clear in the Minister’s answer. The guidance goes on to say:

“It is not racist to ask someone if they have lived lawfully in the UK for the last 12 months as long as you can show that all patients—regardless of their address, appearance or accent—are asked the same question when beginning a course of treatment. The answer to that question may result in others needing to be asked, but again you will not be breaking any laws as long as those questions are asked solely in order to apply the Charging Regulations consistently.”

It is in the guidance that GPs have the right to ask, as long as they ask everybody. They will not be applying a discriminatory process.

As I said, in 2004—they reported in 2009—the previous Government began to consider whether we should extend charging to primary care and how eligibility criteria should be tightened. The review suggested that charging would not be extended to primary care. I hope that we as a Government might be able to reconsider. I know that this Government are committed to ensuring that national health care resources are spent in the right way. My constituents appreciate that, as I have said.

The Home Office has introduced measures so that anyone owing the NHS £1,000 or more will not be allowed to enter or stay in the UK unless the debt is paid. When that is implemented, the Home Office hopes to capture 94% of outstanding charges owed to the NHS; hopefully, it will have a significant impact. Encouragingly, the review commissioned on 18 March 2011 suggested:

“The existing system is still too complex, generous and inconsistently applied. While the NHS remains committed to providing immediate or necessary care, it is important that a balance of fairness and affordability is also struck.”

I agree entirely.

The review taking place will now consider

“qualifying residency criteria for free treatment; the full range of other current criteria that exempt particular services or visitors from charges for their treatment; whether visitors should be charged for GP services and other NHS services outside of hospitals”,

as I suggested; and

“establishing more effective and efficient processes across the NHS to screen for eligibility and to make and recover charges”.

I suggest that as part of the consultation, they consider West Middlesex University hospital and the good work being done there. Finally, the review will consider

“whether to introduce a requirement for health insurance tied to visas.”

I was encouraged when the Minister said:

“The NHS has a duty to anyone whose life or long-term health is at immediate risk, but we cannot afford to become an international health service, providing free treatment for all. These changes will begin the process of developing a clearer, robust and fairer system of access to free NHS services which our review of the charging system will complete. I want to see a system which maintains the confidence of the public while preventing inappropriate free access and continuing our commitment to human rights and protecting vulnerable groups.”

I agree with all those words.

I initiated this debate to ensure that Members have an opportunity to put their views as part of the consultation, which, hopefully, will report later this year. To reiterate, the NHS is a national health service, not an international one. Although we all believe that health care treatment must be free at the point of use, it cannot be free at the point of abuse. I urge the Minister to consider carefully what I have said and what other Members will say in this debate. We care passionately about the NHS. We want the NHS to continue as it has for six decades now. This issue is one that I know all our constituents and everyone in the House, regardless of party politics, will wish to ensure is solved.

--- Later in debate ---

[Mr Jamie Reed (Copeland) (Lab)]

It is a pleasure to contribute to a debate under your chairmanship for the first time, Mr Streeter. I congratulate the hon. Member for Kingswood (Chris Skidmore) on securing the debate. The use of the NHS by foreign nationals is a growing problem and it is important to take a moment to reflect on why we are discussing the issue today. It is a concern among hon. Members from all parties and, as my hon. Friend the Member for Ealing, Southall (Mr Sharma) said, among people representing all communities throughout the country. The issue is of paramount importance to a number of people.

As the previous Labour Government delivered the lowest ever waiting times and the highest ever level of patient satisfaction, along with 44,000 more doctors and 89,000 more nurses, the NHS became the envy of many other countries. The recent Commonwealth Fund comparative study of the state of the NHS makes that absolutely clear. However, a consequence of having one of the—if not the—best health services in the world was, and is, that it became increasingly attractive to foreign visitors. That has brought a number of issues that need to be addressed.

The commonly agreed figure that the hon. Member for Kingswood has mentioned is that the debt accrued by foreign nationals to the NHS is around £40 million. He is right to point that out. It is a lot of money—whether it is £40 million or £60 million—that would buy a lot of medicine and fund a lot of projects in a lot of communities. If the figure is £40 million, it is approximately 0.1% of the £3.5 billion that the Government are wasting on NHS reorganisation now. None the less, that figure is an awful lot of money.

The NHS is built on the principle that it should provide a comprehensive service based on clinical need, not ability to pay. However, at the same time, it is a national health service—not, as has been repeated on a number of occasions, an international health service. There must not and cannot ever be any doubt about that. Therefore, it is right that we impose charges for overseas visitors, who are defined in respect of NHS hospital treatment as people who are not ordinarily resident in the UK.

The previous Labour Government were committed to maintaining the existing system of charges, but they proposed a series of further safeguards, including amending the immigration rules so that anyone who accrued substantial medical debts would not be allowed back into the country if they left without settling their bill. I am genuinely pleased that the current Government have adopted so many of those recommendations. However, we need to look again at the ability to make and recover charges, and we would be happy to work with the Government on that issue. For example, the previous Government considered whether foreign nationals should be charged for NHS services outside the hospital. That issue warrants further close discussion.

We also need to learn from those hospitals that are more successful at recovering charges. The hon. Member for Kingswood referred to some of those. Hospitals have a legal duty to recover any charges made to overseas patients and, frankly, some hospitals need to be much better at that. Sometimes dealing with that problem can be as simple as improving the recording of contact details, so that the patient can be pursued for payment, but I accept that the rules and procedures could be demonstrably improved. The Government should ensure that that is done and, again, we will support them in their efforts to do so.

A relevant issue that has not been touched on today is the Olympics. It would be helpful if the Minister explained what plans are in place to ensure that the NHS can meet the rise in demand from overseas visitors during the games. Will she tell hon. Members what exemptions are in place for athletes and officials? “Newsnight” recently reported that Olympic VIPs could receive fast-track emergency care. With A and E waits already increasing, is there not a danger that taxpayers who are paying for the NHS and the Olympics will be pushed to the back of the queue?

[Chris Skidmore]

I would have raised the Olympics in my speech had it not been for the fact that I wanted this to be a cross-party debate. The criterion that Olympic officials and athletes should receive free treatment was part of the bid that was successful in 2005 under the previous Government. We would not have been awarded the Olympics if that had not been part of the 2005 bid.

[Mr Reed]

The hon. Gentleman makes a good point. He is obviously aware of the fact that although he, I and other hon. Members are privy to those details, the general public are not. There is a salient concern out there about the perceived emergence of a better standard of care being afforded to people who are involved in the Olympics. I visited Homerton hospital in Hackney, which is one—if not the—Olympic hospital in London. I saw some tremendously innovative professionals there who are developing innovative medical treatments and systems of working. They need to get the message across that local people who use that hospital on a daily basis will not be disadvantaged by the Olympics. We need a clear exposition of why that will not be the case.

Although I have considerable sympathy with the contributions I have heard this morning, all hon. Members must recognise that, under the UN convention on human rights, the UK has an international obligation to provide free NHS treatment to those seeking asylum here. All of the contributions I have heard today indicate that that will not be too hard to achieve, but hon. Members must guard against those Members who advocate that we should not fulfil that obligation, because the temptation will be too much for some. When we produce facts and figures used in support of the arguments, that must be acknowledged.

We must also guard against Members from all parties who advocate that the NHS should turn away pregnant mothers or patients in need of emergency care. Overall, this issue requires a diligent, careful approach. It is not the platform for a weird, xenophobic virility contest. I look forward to hearing what the Minister has to say. There may be little common ground between my party and the Government on the NHS, but we can agree that NHS care must always be based on clinical need, not ability to pay. At the same time, first and foremost, the NHS must serve the people of the United Kingdom—those whose taxes fund the NHS, those who believe in it passionately as the guarantor of a better society and those who expect it to be there for them when they need it. I hope that we can agree on that principle as we continue to debate the issue constructively and develop the fair and appropriate policy responses that the issue deserves.