Baroness Jolly: Should we charge foreigners before they use the NHS?

Last week the Government suggested charging people who arrive in the UK before they can use the NHS. Today, as the Lib Dem spokeswoman on health in the Lords, Baroness Jolly was invited to give evidence to the All-Party Parliamentary Group on Migration on the idea. Here is what she told it in full

Baroness Jolly
Baroness Jolly

Warning, I speak for myself today. When I was asked to participate I said we needed a liberal, pragmatic evidenced-based solution, free from dogma,  and it has to be workable.

I do not have time to do a complete analysis, I will just skim the surface and pose more questions than answers.

As we celebrate the 65th birthday of the NHS, we must remember that the NHS has a duty of care to anyone whose life is in danger, to those who have long-term health problems and where there is a risk to public health – and this duty should never change.

However, the NHS is among the world’s most generous providers of free care to overseas visitors and temporary migrants, in contrast to the much stricter German and Scandinavian systems. This has created the issue, certainly within the public perception, of health tourism

Here are a coupe of case studies to ponder. Thanks to Roy Lilley for them.

Two youths in a London A&E: both 15 years old, one is white, has been in a fight in a pub and is drunk, the other is Somalian, sober and the victim of a mugging.  Which one is entitled to free healthcare?

The answer: probably both are as they need first response care.

However, the likelihood is the Somalian lad was born here. The intriguing possibility is the white lad moved south from Glasgow.  Dad lost his job at the Shettleston FreshLink Foods factory a couple of Christmases ago. Therefore, in the terms of some very interesting research by the The Nuffield Trust, he might be counted as a “migrant”.  The Nuffield research gives us pretty well all we have to go on, trying to calculate the extent to which immigrants are “swamping” the health system.

Skin colour is no indicator and this research is the best we’ve got.

Now, work this out. Two Pakistan ladies wearing Hijabs.  One speaks good English, the other almost none.  Which one would you challenge about their entitlement to free NHS care?

The answer?  Who knows?  One might have been here for 20 years, her husband runs his own neighbourhood grocery shop, she’s brought up two kids but never had the opportunity to learn English. The other lady is here on holiday. Command of language tells us nothing. This is not a straightforward issue. So what is the cost of  the perceived problem?

In 2011-2012 the NHS spent £33m on treating foreign nationals, of which around £21m was recovered (through directly charging them or via health insurance, such as the EHIC). The remaining £12m was written off.

As a proportion of the £109bn NHS budget it is almost negligible – just 0.011%! It is not insignificant, however, as it is the cost of 240 nurses.  But the current structures in place mean that the NHS struggles to identify those migrants who are not entitled to free healthcare.

Department of Health figures estimate that only 20-45% of overseas visitors using hospital services are identified and of these just 40% of the costs are recovered. Health Secretary Jeremy Hunt has suggested that the actual cost could be up to £200m pounds.

Whilst the amount is trifling in the context of the much larger NHS budget, in a time of fiscal consolidation, compounded with the demand pressures on NHS services, optimum resource allocation becomes paramount.

The Department of Health in its 2012 review of overseas visitors charging policy has found that the process of screening all patients at the point of admission to determine their eligibility status has significant inherent weakness. It requires staff with specialist knowledge covering multi-site 24/7 access whilst using an identification process which is both burdensome and unreliable.

The administrative cost alone of this process is £15m and with recovery rates estimated between 15-20m, shows that the current system only makes a small net gain (if any at all).

The chair of RCGPs, Claire Gerada, has identified that any new system “may end up costing more to chase fees than would be collected, and meanwhile people with potentially infectious diseases might be deterred from seeking medical help”.

The Department of Health also suggested that the biggest fundamental weakness in the system is the significant financial disincentive to identify and charge visitors. By doing so trusts forego a guaranteed full commissioner payment for the treatment provided, which is replaced by a direct patient payment liability that the trust will likely never recover.

This clearly highlights the issue that the current system lacks the right incentives, as the system does not penalize those trusts who fail to identify migrants but penalises the Trusts who fulfill their duties.

With a system in place which makes it much easier to register a patient as non-EU than it is to chase payments, it has raised the fear (if not certainly a perception) that doctors are being used as a supplementary frontline immigration service.

Both the BMA (in its response to the department of health consultation) and the RCGP’s (Queens Speech – Immigration Bill) have recently rigorously highlighted this point. Laurence Buckman, chair of the BMA’s GP Committee, said: “The BMA would strongly oppose any system where GPs are required to act as UK Border Force agents and enforce immigration checks. Doctors should spend their time treating patients and not acting as the arbitrators of whether patients are eligible to receive NHS care.”

Though the system needs reform, blaming all NHS pressures on migrants is a fallacy. A recent study by the OECD has suggested that migrants make a positive economic impact on our public finances in that they pay more tax then they consume in public services, even when including pension provisions (0.46% GDP). Therefore pro-immigration policies have allowed the government to have lower taxes and higher spending.

The Nuffield Study on migrant usage of health care services published in 2011 also found that migrants registered with GPs were half as likely to use health services in comparison to a similar cohort (in characteristics) of their UK-born counterparts.

Dr Claire Gerada highlighted another important point in a recent debate with Chris Skidmore on Radio 4’s Today. “With respect to immigrants you are much more likely to have an immigrant caring for you than sitting before you in A & E.”

Today around 30% of our doctors and 40% of our nurses in the NHS are born outside the UK. And this proportion is likely to rise, with the increasing care demands and support needs which will arise from an ageing population, compounded by limits in the potential supply of British-born staff.

These figures do not include those eastern European migrants who staff our care homes, often at very low pay levels and many with zero hour contracts whilst undertaking exceptionally important job within our care system.

So back to where I  started. We need a liberal, fair, pragmatic evidenced-based solution, free from dogma,  and it has to be workable.

I hope the APPG is able to respond to the consultation, and maybe invite Jeremy Hunt to a meeting and ask for his evidence base and rationale.

Published and promoted by Tim Gordon on behalf of the Liberal Democrats, both at LDHQ, 8-10 Great George Street, London, SW1P 3AE.

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