Migrants, "fairness" and the NHS

If the government does not have evidence of a significant problem with “health tourism”, why is it proposing setting up an expensive and cumbersome system to address it?

Juan Camilo
29 July 2013
migrant child healthcare.jpg

Image: VivirLatino. Creative Commons Licensed.

Last month the government published two consultations to extend the current provisions for charging migrants to access NHS services.

Hospitals and other secondary care providers can already charge patients who are not ordinarily resident in the UK (short term visitors, migrants without status and citizens living abroad). But primary care, including vesting a GP, has until now remained free of charges and open to most patients. At present GPs have discretion to register anybody in the UK.

The new measures propose charging temporary migrants a levy of at least £200 per year to allow them to use the NHS, including primary care. This would apply to anyone who is not settled - including tourists and migrants without indefinite leave to remain. Alongside this are proposals for a new system to identify chargeable patients, and a strengthening of the mechanisms to recoup charges from other European countries when their citizens access UK healthcare.

These are big changes for the NHS, built on the premise of free service at the point of use. It involves charging a significant number of people (up to 950,000 by the Department of Health’s own estimates) who are living in the UK for a considerable period of time.

To implement it the government would have to develop a system that can identify those who should be charged. This could be a mammoth task. All those new to the NHS would have to register before accessing any services. People would have an NHS record containing information on whether they are eligible for free treatment. If this were to be extended to the population already present in the UK, the Department of Health reckons it would be “an enormous administrative burden as well as a huge imposition on a large number of UK residents.”

Would all this effort reduce costs for the NHS or provide better health outcomes? The Department of Health does not know. It acknowledges the evidence is just not there, but has commissioned an ‘audit’ to try and produce it.

Talk like a Conservative

The reviews have been caught up in Cameron’s toughening language on migrants. The inter-ministerial group on migration he set up earlier this year was, according to one ex-minister, initially called the “hostile environment working group”. Cameron vowed to “make sure that ours is the toughest country instead of the softest”. He told his ministers “tear up your departmental brief, I’m not interested in what you were told to say when you came to this meeting; rip it up, think like a Conservative and make sure you’re really doing what is necessary to ask the difficult questions in your department.”

Cameron claims Britain’s “generosity” to migrants attracts them to the UK, and that he wants to restrict migrants’ access to public services to reduce so-called “pull” factors.

In fact there is little evidence that access to services plays a determinant role in attracting migrants to the UK. Whilst the £200 migrant levy may push the already very high visa fees beyond the tipping point for some, many others will just cough up, even though they will also be contributing to fund the NHS through their taxes while in the UK.

A public health disaster

The proposed changes will hurt the most vulnerable migrants: undocumented migrants who cannot or will not return to their countries of origin, and especially those living in or near destitution. Many have been in the UK for many years and have ended up in their predicament partly due to the malfunctioning of the immigration system. They will have to pay per visit to a GP. Many of them will not have the means to do so.

The Department of Health claims that treatment of infectious and contagious conditions will remain free. But for most patients the main point of contact with the health service is the GP surgery. With access to a GP restricted by capacity to pay, it will be more difficult to identify those conditions amongst chargeable patients, with potential implications for public health. In areas where there may be significant numbers of destitute irregular migrants, health authorities will also find it more difficult to deliver on their duty to address health inequalities.

Bad economics, inhumane policies

Charities, medical professionals and migrant support groups agree that it is better for everybody if vulnerable people get timely medical attention at the primary care level. It allows for conditions to be diagnosed and treated early, rather than being left untreated and becoming much more costly to treat down the line. Without free access to primary care, patients will merely turn up at A&E requiring immediate treatment which cannot be refused.

Identifying and charging patients at secondary care level has not proven to be cost effective. Last year’s Department of Health review into access to healthcare estimated that between £15 -£25 million pounds were recovered by Trusts from chargeable patients. It estimates the cost of recovering these monies at £17million with an extra £1million lost in staff time and excluding other costs such as the use of debt recovering agencies. The document thus states ‘it is not clear whether the OV charging system is generating a net benefit to the NHS or whether the costs of operating it outweigh the income generated.’ There is a significant risk that extending charging to primary care will not result in a net gain for the NHS and could cost more than is recovered.

We know of many individuals who have gone through considerable pain and stress with conditions relatively simple to treat because they could not register with a GP, even in the current open system. One patient I spoke to recently had a tooth infection that spread through his jaw and into his neck area. He had struggled to register with a GP because he had wrongly been asked for proof of his immigration status. As the pain spread, so did his stress and anxiety. He did not know what was wrong. With the support of a charity he eventually got registered, saw a GP, was diagnosed and prescribed a course of antibiotics that got rid of the infection. Had he remained excluded from primary care, given that he was unable to pay for a consultation as a private patient, this man would have ended up needing expensive A&E treatment.

The economic, public health and medical arguments for universal access to primary care are why strategic health authorities have worked for many years with migrant support groups trying to encourage migrants to register and visit a GP. Now all this work will be put at risk.

Abandoning fairness and NHS principles

We have heard a lot about whether it is ‘fair’ for migrants to be able to use NHS services at no cost to themselves. In fact, migrants as a group are net contributors who pay more in taxes than they take out of the system. Migrants tend to underuse the NHS. On average they are young and healthy and many use their own health systems or private doctors for treatment.

The consultation proposes that an over-arching principle for the NHS is that ‘everybody makes a fair contribution’. The government has repeatedly suggested that recent migrants should not be eligible for free NHS care because they have not contributed to it. Announcing the consultation the Secretary of State said that ‘we need to ensure that those residing or visiting the UK are contributing to the system.’ The consultation argues that ‘Visitors and newly arrived migrants from non-EEA countries should contribute explicitly for NHS services until they are fully integrated in our residency system and its social provision.’

A key NHS principle is being undermined here. The NHS is not funded through specific contributions - it is funded by general taxation. And all migrants pay taxes one way or another. If the proposals are implemented, migrants would in effect be paying twice - once through the levy and a second time through taxation.

There are no clear medical, public health or economic arguments to suggest the proposals will make the NHS more sustainable. There are huge risks. The politics of immigration, rather than evidence, seems to be the driver of the proposals. The government is using concerns about migration to drive through a notion of ‘fairness’ in which individuals only benefit from services in proportion to what they have contributed. In all this discussion the role for compassion and better societal outcomes is in danger of being lost, alongside key NHS principles.

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