TUC comments on Government plans to charge migrants to use NHS

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Department of Health Consultation on migrant access and their financial contribution to NHS provision in England

August 2013

I. Introduction

The Trades Union Congress (TUC) has 54 affiliated unions, representing almost six million members, who work in a wide variety of sectors and occupations. The TUC has a long history of opposition to racism and xenophobia, and has consistently highlighted and campaigned against discrimination against black and minority ethnic (BME) workers in the British labour market. The TUC believes in a rights-based approach towards migration which ensures equal rights for people at work whether they are indigenous or migrant workers. The TUC welcomes the opportunity to respond to the Department of Health's consultation on migrant access and their financial contribution to the NHS provision in England as we have serious concerns about the premise on which the proposals are founded as well as the negative impacts they are likely to cause.

II. The myth of 'health tourism'

The consultation states that upfront health charges for non-EEA citizens are necessary due to the fact 'the NHS struggles to identify and recover the cost from those not entitled to free treatment...We know that this is a significant problem.' The consultation document does not provide data to support this assumption - in fact it states an audit into the use of NHS by overseas visitors will only be conducted in the autumn. NHS data suggests that non-payment of fees for secondary care which currently incurs charges for temporary non-EEA migrants is not a considerable cost for the health service. Non-payment of health fees by non-EEA migrants currently represents 0.011% of the NHS budget. The impact of this cost is small in comparison to the £20 billion of savings that the Government's austerity cuts have imposed on the NHS. Furthermore, the non-payment of fees for secondary care may be due to lack of NHS resources to contact and locate the patient or the patient being deceased, rather than deliberate fee evasion.

The TUC believes it would be more efficient and equitable to eliminate health charges for non-EEA citizens rather than introduce additional charges for them and accompanying document checks and a new registration database to cover every patient in the NHS, as the Department of Health is proposing.

Consultation questions

1. Are there any other principles you think we should take into consideration?

The four overarching principles outlined by the consultation are important as they indicate the core principles of the NHS that any proposed changes must not alter. The TUC is concerned that the proposals to charge non-EEA migrants contradict these overarching principles.

Principle 1 - the NHS 'ensures access for all in need'

Introducing charges for non-EEA citizens would exclude this category from all but emergency access to healthcare for those who could not pay.

TUC believes health care should be free at the point of need as to refuse to treat someone on the basis that they have not produced evidence of payment goes against the UK's obligations as a signatory to the Universal Declaration of Human Rights which includes a right to medical care and the International Covenant on Economic, Social and Cultural Rights requires states to take the necessary steps to create conditions ensuring access to healthcare for all.

The UK is obligated as a signatory to the Universal Declaration of Human Rights and International Covenant on Economic, Social and Cultural Rights to take necessary steps to ensure access to healthcare for all.

Whilst the consultation notes that: 'if an emergency need arises, they will not be refused care but will be charged at the point of delivery', there are a number of non-emergency conditions that will become emergency treatments if not addressed at an early stage, thus denying primary care becomes a denial of non-EEA citizens' basic rights to care. Antenatal care is a clear example - if a woman is a non-EEA citizen and cannot afford the significant cost of antenatal care a number of health complications may develop with her and her unborn child. She would then have to resort to using the Accident and Emergency services, endangering her health. Primary care is also essential for detecting conditions such as cancer and diabetes which become debilitating if not detected early on.

Denying primary care access to those who need it also poses a public health risk. Whilst the consultation document states there will still be exemptions for treatment of infectious diseases and sexually transmitted infections (STIs), it would be very difficult putting such an exemption into practice. Often people are not aware when they have a communicable disease. Such diseases are often only spotted in routine GP check-ups or during ante-natal screening. If non-EU citizens cannot afford the upfront fees for healthcare they are unlikely to get their symptoms checked by a health professional on the off-chance they might have a communicable disease as there is a risk that they may have to pay for their treatment if their disease is not communicable. Rates of undiagnosed HIV and late diagnosed HIV are 25% and 50% respectively. If charges exclude women from receiving such care then STIs will not be detected and treated, creating a public health risk.

Primary care is the site where the majority of immunisations take place that would guard against diseases that pose a public health risk such as measles and TB. Even if children are exempt from charging, parents who have not registered with a GP because of their own chargeable status may not be aware of the importance of vaccinations and may be fearful of taking their children to the doctor for immunisations for fear of charges.

A further public health risk is created by the fact that these proposals risk the well-being of the considerable number of health professionals who are non-EU citizens. If medical staff have infectious diseases that have not been diagnosed due to their inability to pay upfront fees, then all those patients in their care are endangered.

Principle 2 - the NHS is 'a system where everybody makes a fair contribution'

The TUC believes that introducing upfront charges for non-EEA migrants to use health services which they have paid for as much as EEA citizens is not a fair arrangement. The NHS is funded from general taxation which everyone in the country contributes to, including non-EEA migrants, through tax contributions whilst working or simply through paying VAT in everyday consumption. Non-EEA migrants also contribute additionally to the NHS as health workers who maintain the service. IPPR estimated that in 2003, 40% of nurses were non-EEA citizens.[2] There is also unfairness in the exemption of certain non-EEA citizens from charges but not others. The consultation proposes that former legal residents of the UK not subject to immigration control who have paid NI for a significant period - 7 years - will retain access to all NHS treatment free of charge.

Principle 3 - the NHS is 'a system that is workable and efficient'

The TUC believes that the proposed charge for non-EEA citizens to access health care will be unworkable and bring about significant inefficiencies to the NHS. In order to implement the charges, users of health services would be required to prove their immigration status and, if they were non-EEA citizens, whether they had paid to use health services, either in the form of a levy, as the Government prefers, or health insurance. The consultation states that to make this possible a large-scale IT system would have to be introduced in the NHS. The cost of introducing such a new system and training staff would negatively impact on the ability of the NHS to function, as it is already damaged by having to make billions of pounds of savings to meet Government austerity plans. Such a system of checks would also introduce inefficiencies as each patient would need to be checked each time they used a health service, causing increased delays on services that are already stretched. Furthermore, the consultation makes clear that health workers will 'have a role in identifying chargeable patients'. The TUC has serious concerns that the measures would turn health professionals into immigration officials. This will impede the ability of medical staff to provide essential care and cause an administrative burden that the NHS is ill-equipped to cope with due to budget cuts.

Principle 4 - the NHS is 'a system that does not increase inequalities'

The TUC believes the proposals are in direct contravention of this as they are likely to increase inequalities by obstructing access to health care for already vulnerable and marginalised groups -such as women, migrant, BME, asylum, refugee and disabled communities. This is discussed further in Question 2, below.

2. Do you have any evidence of how our proposals may impact disproportionately on any of the protected characteristic groups[3]?

The TUC is concerned that the proposals may lead to discrimination in frontline service delivery to individuals with the protected characteristics of gender, race and ethnicity. People who are not white or do not speak English fluently are more likely than their white English-speaking counterparts to have their entitlement questioned by those administering the system. This would compound inequalities already experienced by ethnic minority citizens who are already marginalised in their ability to access care due to issues of language and lack of accessible information.

These proposals are also likely to impact negatively on asylum seekers. Although the proposals exempt asylum seekers (and refugees) from health charges, clinics may not understand these rules. Evidence from Still Human Still Here shows that asylum seekers are already more likely to be turned away from treatment by GP surgeries that believed they were not entitled to care. This will discriminate against a group in particular need of care. According to a recent study, just under 25% of asylum seekers the group displayed symptoms consistent with post traumatic stress disorder and 35% of cases were assessed as being at significant risk of suicide.[4]

These proposals are also likely to disproportionately impact people with disabilities and mental health issues. These conditions require long-term treatment which non-EEA migrants may no longer be able to fund, leaving them without the critical care they need.

The TUC is concerned about the impact of these proposals on women. Women are more likely to be living in the UK as dependents of a spouse. GPs are often the first port of call for women seeking contraceptive advice, a termination to an unwanted pregnancy, or when suffering domestic violence. If charges for primary healthcare are to be introduced, women will be fearful of accessing services which they can no longer afford. Pregnant women who are unable to afford NHS charges may go through the pregnancy without any access to antenatal care, thus increasing the risk of complications which are dangerous and costly to manage later in the pregnancy, such as pre-eclampsia, gestational diabetes, anaemia and urinary tract infections. Many women will give birth without any medical assistance - as already happens in a small but significant number of cases per year - thus endangering the life of both the mother and the child. Research has shown that, compared to white women born in the UK, BME women born outside the UK booked for antenatal care later, had poorer information provision and were less likely to be treated with respect by staff.[5] In 2011, the majority of pregnant women who attended the Project:London's clinic in East London, established for migrants, the homeless, and female sex workers, were already in the second trimester of their pregnancy or beyond, without so far accessing antenatal care.[6] Given that charging already exists for medical terminations, pregnant women could find themselves in the invidious position of being unable to afford a termination and unable to afford NHS antenatal care and medical attention in labour.

3. Do you have any views on how to improve the ordinary residence qualification?

The TUC does not believe that the current 'ordinary residence' qualification should be changed. The current definition recognises the important eligibility criteria of the 'settled' nature of someone's life in the UK, which better captures the principle of 'fair contribution' as those who are 'settled' in the UK pay into general taxation that funds the NHS, as discussed in Question 1. The 'ordinary residence' qualification is also a broad definition which does not link eligibility to specific immigration and residency status, categories which are subject to regular change by the Home Office, and therefore avoids the risk of unintentionally excluding those who are entitled to, and need, NHS care.

4. Should access to free NHS services for non-EEA migrants be based on whether they have permanent residence in the UK?

No. As outlined above, non-EEA migrant workers already contribute to the NHS in exactly the same way as other people in the UK. The NHS is funded through general taxation, not solely through National Insurance contributions - this is not an 'indirect' contribution. A significant number of migrant workers are themselves employed in the health service and thus additionally contribute to the NHS through their work.

5. Do you agree with the principle of exempting those with a long term relationship with the UK (evidenced by National Insurance contributions)? How long should this have been for? Are there any relevant circumstances under which this simple rule will lead to the unfair exclusion of any groups?

While the TUC believes that people with a long term relationship with the UK should receive free NHS care, it does not believe this should be defined in such a way to deliberately exclude non-EEA migrants who currently receive free primary care.

6. Do you support the principle that all temporary non-EEA migrants, and any dependents who accompany them, should make a direct contribution to the costs of their healthcare?

No. As outlined above, non-EEA migrants already contribute to the NHS in the same way as other people in the UK. The NHS is funded through general taxation, not solely through National Insurance contributions. As mentioned above, significant numbers of migrant workers are themselves employed in the health service and thus additionally contribute to the NHS through their work.

7. Which would make the most effective means of ensuring temporary migrants make a financial contribution to the health service?

a) A health levy paid as part of the entry clearance process

b) Health insurance (for NHS treatment)

c) Other - do you have any other proposals on how the costs of their healthcare could be covered?

Other - The TUC believes that migrants who come to the UK for an extended period (more than six months) already contribute to the NHS through their regular taxation (VAT, income tax and NI contributions).

The TUC is concerned that the Department of Health consultation document does not contain a clear financial estimate for the cost of implementing these proposals which seems likely to far outweigh any financial benefit accrued. As stated above, introducing charges for primary health care will force non-EEA temporary visitors who cannot afford these fees to go to Accident and Emergency for treatment. This both increases the risk to patient's health and significantly increases the cost to the NHS. Maternity Action estimate that the cost of an emergency caesarean section and the cost of inpatient care for a very premature baby that could result from lack of antenatal care would be £59, 273 whilst the cost to the NHS of providing antenatal care and a normal birth would be just £3,560.

There would also be significant costs in creating the IT and administrative support systems required to document citizens' immigration status into their health records and the substantial expansion of the Biometric Residency Permit (BRP) system that these proposals would require.

8. If we were to establish a health levy at what level should this be set?

a. £200 a year

b. £500 a year

c. Other amount (please specify)?

C - no charge should be applied.

9. Should a migrant health levy be set at a fixed level for all temporary migrants? Or vary according to the age of the individual migrant?

The TUC does not believe a migrant health levy should be imposed.

10. Should some or all categories of temporary migrant be granted the flexibility to opt out of paying the migrant levy, for example where they hold medical insurance for privately provided healthcare?

The TUC does not believe a migrant health levy should be imposed and introducing further complexity in the charging system will create more administrative burdens on the NHS which is already being forced to make large savings under Government austerity policies.

11. Should temporary migrants already in the UK be required to pay any health levy as part of any application to extend their leave?

No. The TUC does not believe a levy should be introduced for those who have been living in the UK for a considerable period. As discussed in Question 2, denying access to healthcare for one category of citizens is unjust on humanitarian grounds whilst it is economically unjust as non-EEA citizens contribute to the NHS as much as EEA citizens as they pay taxes through their work and consumption in the UK.

12. Do you agree that non-EEA visitors should continue to be liable for the full costs of their NHS healthcare? How should these costs be calculated?

No. By denying non-EEA visitors access to healthcare on the grounds of cost certain conditions may become more serious and need to be treated in A+E which would be more costly, as discussed in Question 7. There are also public health concerns that upfront charges will deter non-EEA visitors from being checked when they have a communicable disease that would endanger all citizens, as discussed in Question 1.

13. Do you agree we should continue to charge illegal migrants who present for treatment in the same way as we charge non-EEA visitors?

No. The current approach of charging migrants with irregular statuses for care should not be continued. They are largely a very vulnerable group of people who may have irregular status due to changes in Immigration rules - domestic workers are a significant example. The introduction of the new Domestic Worker Visa in 2011 meant that domestic workers lost the right to change employers. This means they do not have a means of legally escaping exploitation and abuse by employers which Kalayaan show is a common experience for domestic workers.

Denying such workers the access to healthcare will increase their vulnerability and means any condition they have will become an emergency condition that will cause them much more harm and, as discussed, will be more costly for the health service as it will need to be treated in Accident and Emergency.

14. Do you agree with the proposed changes to individual exemptions? Are any further specific exemptions required?

The TUC does not believe there should be any charges for non-EEA citizens to access to healthcare, obviating the need for exemptions. The TUC notes, however, that the category of pregnant women and children are missing from the exemptions under international obligations listed in the consultation document. The list below details the international agreements which oblige the UK Government to exempt these groups from health charges:

UN Convention on the Rights of the Child - Article 24: the state must provide every child present on UK territory the same healthcare services as nationals

UN Convention on the Rights of the Child - Article 4 (Protection of rights): the state must take all available measures to make sure children's rights are respected, protected and fulfilled; and

UN Convention on the Elimination of all forms of Discrimination Against Women (CEDAW) - Article 12: the state must 'grant free services where necessary, as well as adequate nutrition during pregnancy and lactation.'[7] In its concluding observations on the seventh periodic report of the UK Government to CEDAW, the committee noted that the state should: 'Provide access to justice and healthcare to all women with insecure immigration status, including asylum seekers, until their return to their countries of origin.'[8]

15. Do you agree with the continued right of any person to register for GP services as long as their registration records their chargeable status?

The TUC believes that every person has the right to register for GP services, regardless of status.

16. Do you agree with the principle that chargeable temporary migrants should pay for healthcare in all settings, including primary medical care provided by GPs?

The TUC does not believe that temporary migrants should be charged for health care for the reasons discussed above.

17. Do you have any comments or ideas on whether, and if so how, the principle of fair contribution can best be extended to the provision of prescribing ophthalmic or dental services to visitors and other migrants?

The TUC does not believe charging should be extended to these services.

18. Should non-EEA visitors and other chargeable migrants be charged for access to emergency treatment in A&E or emergency GP settings?

No. Any delays caused by ambiguities about eligibility could have disastrous and potentially fatal consequences. Healthcare professionals are there to provide emergency treatment in those settings without having to check on status, on top of existing pressures to meet urgent needs in a very challenging healthcare environment.

19. What systems and processes would be needed to enable charging in A&E without adversely impacting on patient flow and staff?

The TUC does not believe there are any systems or processes which could enable charging in Accident and Emergency without adversely impacting on staff or patient access to emergency services. Any system which could accurately tell healthcare staff who to charge and who not to charge whilst also not being 'intrusive' for non-chargeable users would be difficult to achieve. In the event of any breakdown, short cuts taken to identifying chargeable patients could lead to discrimination.

20. Do you agree we should extend charges to include care outside hospitals and hospital care provided by non-NHS providers?

Many of these services are specifically there to meet the needs of vulnerable people who have difficulty accessing healthcare. Extending charges to these settings would be counterproductive.

21. How can charging be applied for treatment provided by all other healthcare providers without expensive administration burden?

This could not be done without an expensive administrative burden. The TUC believes that proposals to extend charging to primary care could not be done without a prohibitively expensive administrative burden either.

22. How else could current hospital processes be improved in advance of more significant rules changes and structural redesign?

The NHS has just gone through the largest and most turbulent structural upheaval in its history, so more reorganisation in order to implement the type of proposals outlined here is the last thing that those working in hospitals or the wider NHS want to see happen.

23. How could the outline or design of the proposal be improved? Do you have any alternative ideas? Are there any other challenges and issues that need to be incorporated?

As discussed above the TUC believes that the design of the proposal is fundamentally flawed. It will be extremely expensive, place greater pressure on services which are currently underfunded and very stretched for very little benefit. Indeed, the main outcome of these proposals will be to undermine the health of vulnerable groups of people, an undermining of the ethos of the NHS.

It will also intrude into the relationship between all patients and the NHS, as everyone will be required to prove their eligibility for free care. The proposals do not explain how this will operate without harming patient care or undermining the relationship between patients and healthcare staff.

Accessing healthcare under these proposals will be dependent on IT systems. Any breakdown or lack of speed in updating patient records might mean that non-EEA migrants who are eligible for care might be denied it. There are also significant data protection issues not only for non-EEA migrants but for all NHS patients.

24. Where should initial NHS registration be located and how should it operate?

The TUC believes that NHS registration should remain with GP practices.

25. How can charges for primary care services best be applied to those who need to pay in the future? What are the challenges for implementing a system of charging in primary care and how can these be overcome?

The TUC believes that the significant practical difficulties and financial burden caused by a system that charges for primary care for some citizens combined with the social impact of increase in the inequalities, discrimination and damage to public health that would be caused by such a system presents insurmountable barriers to such proposals. The TUC believes that instead of pursuing such policies, the Government should put resources into providing a better health service for all citizens so that public health is improved and vulnerable groups receive the care they need.

26. Do you agree with the proposal to establish a legal gateway for information sharing to administer the charging regime? What safeguards would be needed in such a gateway?

No. The TUC does not agree to the establishment of a legal gateway for information sharing such sensitive personal data. It raises significant data protection concerns.



As defined in the Equality Act 2010: age, disability, gender reassignment, race, religion or belief, sex, sexual orientation, marriage and civil partnership, and pregnancy and maternity

Polly Nyiri, A specialist clinic for destitute asylum seekers and refugees in London, BJGP, November 2012.

Redshaw, M. and Heikilla, K. (2010) Delivered with care: A national survey of women's experiences of maternity care in 2010. National Perinatal Epidemiology Unit https://www.npeu.ox.ac.uk/files/downloads/reports/Maternity-Survey-Repor...

Ramaswami, R. (2012)'Why migrants mothers die in childbirth in the UK', Open Democracy, 12th January 2012 http://www.opendemocracy.net/5050/ramya-ramaswami/why-migrant-mothers-di...


UN CEDAW Committee: Concluding observations on the seventh periodic report of the United Kingdom of Great Britain and Northern Ireland*, paragraph 57 (p.10), July 2013

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