My Lords, I have two amendments in this group—Amendments 59 and 63. I declare my interests, which are in the Lords’ register.
We received a very interesting letter from my noble friend Lord Howe over the weekend. His letter explains that Clauses 33 and 34 are designed to break, or perhaps put a stop to, the activity of health tourism. It is absolutely right that we should do that. Having read his letter, I understand that estimates suggest that between £70 million and £300 million of costs—it seems to be rather a large gap—are attributed to people who deliberately travel to England to get free healthcare because their treatments are so expensive in their country of origin. In no way should we entertain health tourism; it should be detected and the individuals suitably charged. The NHS, as we know, is enormously generous and supported by us all through our taxes. The whole purpose is that we should contribute, through our taxes, to the well-being of our own country’s health.
I have had a long-time interest in maternity services. As the noble Earl, Lord Listowel, indicated in introducing his proposed new pregnancy and maternity clause, there really are few things more important to a woman than bringing a new life into the world. It is a journey of dramatic physical, psychological and social change; of becoming a mother, of redefining family relationships and in taking on the long-term responsibility of caring for and cherishing a newborn child. If the needs of child-bearing women and their babies are ignored, then not only are the physical, social and psychological long-term effects damaging to those concerned but the economic implications for the country are considerable.
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As I understand it, the present rules charge women for maternity care if they are not “ordinarily resident”—that is, if they do not have permission to live here permanently. However, they can gain the status of being ordinarily resident immediately or shortly after they enter the country. Women whose status attracts a charge receive an invoice for their care, often early in their pregnancy. If they are unable to pay, though, they should not be refused care. The reason for that is that maternity care is classed as “immediately necessary treatment”, which means that it should not be refused or delayed for any reason. This is because we know that the consequences of delay in extreme circumstances can mean the loss of life or serious damage to the mother, the child or both.
If a woman does not pay, the Home Office may be notified and choose to deny subsequent immigration applications until the debt is paid. While the rules state that women should not be refused care if they are unable to pay, there is evidence of women who are wrongly refused care. There is evidence of women deterred from seeking care because of the charges and the impact of such a debt on subsequent immigration applications. These rules are very poorly understood by migrant women and are very poorly implemented by the NHS. The government research suggests that as many as 30% of the people assessed by NHS trusts are incorrectly classified, resulting in charges being imposed on people entitled to services free of charge.
The research that has been undertaken by both the BMA and Maternity Action highlights the confusion among staff not knowing who is to pay and who
should receive care free at the point of use. Secondary legislation under Clause 33 of the Bill will not solve this problem, as I see it; instead, it could make the situation a lot worse. The clause enables the Secretary of State to introduce a migrant levy as part of applying for a visa, as the noble Earl, Lord Listowel, has said. It will significantly increase the number of migrants who are subject to charging, and it will expand the NHS services that attract a charge.
My concern is that, if charges are introduced, they will create a risk that women will not attend antenatal care or will be denied access to services because of their inability to pay. This could prevent midwives from identifying and treating health conditions early in pregnancy, leading in turn to significantly worse health outcomes for these vulnerable women.
As with every piece of legislation, we must try the “What if?” tests. What if a woman finds herself pregnant after her relationship has broken down? If she was dependent on her husband or partner for her immigration status, is she to be charged for maternity care, GP care, prescriptions and dental care? What if a woman whose asylum claim was refused, and is destitute and living on the streets, becomes pregnant as the result of a sexual assault? Is she to be charged for maternity care, GP care, prescriptions and dental care? What if a woman who is married to a British man and has submitted an immigration application to the Home Office becomes pregnant and gives birth while the application is being assessed? Is she to be charged for maternity care, GP care, prescriptions and dental care? Nationally, 20% of all maternal deaths are to women who started their care late in pregnancy, estimated as after 22 weeks, who have missed more than four antenatal visits or who have had no antenatal care at all.
My Amendment 63—I thank other noble Lords who have put their names to it—addresses the needs of migrant women, who have significantly worse maternal health than the rest of the population and have sicker babies. NICE recognises this. NICE guidance identifies migrants, refugees and asylum seekers as a distinct risk group. It recommends that additional measures to promote their early involvement in maternity care should be followed. Screening during antenatal care enables midwives to identify and treat diseases such as HIV and hepatitis. These diseases can be passed on to the baby. Rubella and syphilis can cause serious abnormalities in the baby. The risks associated with FGM can be averted when it comes to labour and the birth of the baby. Lastly, conditions that might lead to early labour can be assessed, for example, blood pressure, urine infections and multiple pregnancies.
Even under the present system, we have cases of women who have been deterred from seeking care. I want to mention just one. A woman who had experienced problems with her first baby was found to have high blood pressure during her second pregnancy. Her doctor wanted her to be admitted to hospital, but she refused because she was fearful of being charged for maternity services. This woman had been charged for NHS care for her first baby. She attended an appointment with a midwife during her second pregnancy, but refused to go to hospital despite strong recommendations from
the midwife and the doctor. By the end of her pregnancy, she was very ill, and when she gave birth, her baby was very unwell. The woman’s kidneys failed. She was admitted to the intensive care unit and now requires long-term dialysis. The ongoing poor health of the woman and her baby could have been prevented had she received the care that she needed earlier in her pregnancy.
The final costs of deterring women from attending antenatal care can be considerable. The simple process of identifying and treating a common complaint in a pregnant woman, such as a urinary tract infection, can prevent a woman developing an inflection of the kidneys, which can result in a premature birth. The cost of delivering standard care, including treatment of a urinary tract infection is £2,600. The cost of providing care to a woman with kidney failure and her premature baby is £59,000. Diagnosis and treatment of HIV during pregnancy can reduce the risk of HIV transmission to the baby to a negligible level. The cost of providing maternity care and HIV treatment is between £15,000 and £24,000, depending on the treatment, but the lifetime cost of care for a baby born with HIV infection is at least £280,000.
I can understand the wish of the Government to simplify the present system, but they must ensure that the proposed changes will not deter some pregnant women from seeking and accessing maternity care. It is important that these clauses do not have a negative impact on the health of these women and their babies and perversely lead to a need for more medical care at greater cost.
My Amendment 63 is carefully drawn. It identifies women who should not pay charges but does not restrict the Secretary of State adding to the categories, should he wish. It also gives him flexibility through guidance, and it gives discretion to providers of services in identifying whether there are reasonable grounds about whether charges should apply in certain circumstances. My concern is that, in trying to deter pregnant women from health tourism, the ultimate result will be that we will be left with a higher bill to pay nationally and will cause considerable misery on the way. I look forward to my noble friend’s reply.