My Lords, I shall speak to Amendment 59, which stands in the name of the noble Baroness, Lady Cumberlege, and to Amendment 60, which stands in my name. I have added my name to Amendment 59. I also strongly support Amendment 63, which stands in the name of the noble Baroness, Lady Cumberlege, and other noble Lords. I would have added my name to it, but another Lord Patel—the noble Lord, Lord Patel of Bradford—beat me to it. I think the priorities were wrong there, but never mind. It just shows that Amendment 63 has wide, cross-party support in the House.
I declare my interests. I am on the specialist register of the General Medical Council as an obstetrician. I also hold the position of professor of obstetrics at the University of Dundee. The noble Baroness, Lady Cumberlege, gave a long list of reasons why pregnant women should be seen early in pregnancy, and I could add another 500 or more, but I do not want to recite a
textbook of obstetrics and antenatal care. It is important that every pregnant woman is seen as early as possible during pregnancy if we are to prevent problems occurring later in pregnancy for her and her child’s well-being. It is important that she is seen early so that problems that are occurring are identified early and can be treated early to prevent serious complications developing later. As the noble Baroness, Lady Cumberlege, said, in maternal mortality reports, it is the women who are seen late in pregnancy who develop the most complications and even die. Hence anything we do that will prohibit or prevent women from being seen early in their pregnancy will be wrong.
As for health tourism, the visitors are not part of this levy or these charges. It is likely that the so-called childbirth tourism occurring here, often referred to by some hospitals as the “Lagos shuttle”, is about visitors and not those seeking to enter this country on different visas. I therefore hope that the Minister will look again at why pregnant women are included in the levy and charges.
My Amendment 60 includes not only persons who are pregnant but also children. To clarify, I included children under 18 because, currently, children under 18 in this country are exempt from NHS charges. Of course, I realise that, in terms of risk, children under five years old are different from children aged five to 12 or, for that matter, 12 to 18. As no other noble Lord is likely to speak about children, although the noble Earl, Lord Listowel, referred to them briefly, I intend to speak at length only to demonstrate how important children are and what harm the levy, or imposing charges on children, could possibly do.
My amendment would exempt children from the migrant health levy when they apply or are included as dependants in an application for leave to enter or remain. The levy is to apply generally to visa applicants who are students, workers or families, but not visitors. Currently, it is intended that payment of the levy will provide the applicant with free access to all NHS services for the duration of his or her visa. As the noble Baroness, Lady Smith, said, we need clarification about whether the levy means that they will get all NHS services free of charge. There is a lot of confusion about that. For instance, Clause 33(4) makes it clear that there is no guarantee that restrictions on access to particular services will not be introduced. Clause 33(3)(e) includes a power for the Secretary of State to make exemptions from the levy. However, it is not clear in the Bill what the consequence of such an exemption would be. Without more, it appears that a charge would be made where a child exempted from the levy needed to access NHS services, save for any services which regulations may exempt from charging.
As to which services charges will apply, the intention is that this will include primary and secondary care services, including accident and emergency services. GP consultations will be free, although it is unclear whether any treatment that may be delivered by or via the GP will be free. Treatment for specified communicable diseases and sexually transmitted infections will be available. It is yet to be decided whether any, or how many, mental health services will remain free. There is a great deal of doubt.
The Department of Health response to last year’s consultation on migrants’ access to NHS services recorded,
“widespread support for exempting all children, not just those in local authority care, from charging”.
However, the Government then concluded:
“We do not intend to establish an exemption for children as we believe this poses a significant risk of abuse by visitors seeking treatment for children … Vulnerable children, such as victims of trafficking, those seeking asylum, and migrant children in local authority care currently receive free healthcare and will continue to do so. We will listen to arguments about how best to cover other vulnerable children who might otherwise be denied treatment”.
Can we know what this group of “other vulnerable children” will be? To me, all children of a certain age are vulnerable.
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Therefore there are several problems with the Government’s position. First, the suggestion that exempting children would encourage migration to the UK is mere speculation. Research has found no correlation between accessibility of healthcare to migrants and migration patterns. That some people may abuse that is different, but it does not encourage migration. Secondly, not all children falling within the groups specified as vulnerable are in practice recognised as within those groups. As the Department of Health response acknowledges, victims of human trafficking are exempted from charges only if they have been formally recognised as victims or potential victims, and most do not engage with the formal recognition system. If they do not do so, they are not recognised. Child asylum seekers may also be excluded by reason of disputes as to their age.
Thirdly, the Government’s position fails to have any regard to the effect of greatly extending charges to cover primary care and accident and emergency treatment. While children are not generally exempted from NHS charges now, the consequences of this are less harmful because primary care and accident and emergency treatment are currently provided free. Fourthly, the Government’s position seeks to draw a generally inappropriate distinction between children who are vulnerable and those who are not. While some children face greater risks to their health and well-being than others, all children are vulnerable to such risks by reason of their physical and mental immaturity and their dependency on parents or guardians. That is why we look after our children—because they are vulnerable.
If the Government proceed with their current proposals, children face being effectively excluded from basic primary care and accident and emergency treatment if they or their parent or guardian are deterred because they cannot afford to pay a charge, are worried about the consequences—including immigration consequences—of incurring a debt they cannot afford, or are simply afraid that if they seek healthcare, the Home Office will be informed. Clinical experience shows that individuals and families are already deterred from accessing health treatment they need. The Royal College of General Practitioners said that,
“we are concerned that limiting access to primary care would impact detrimentally on immunisation rates”.
At Second Reading, the noble Lord, Lord Taylor of Holbeach, offered the reassurance that,
“claims that we intend to turn GPs into immigration officers are untrue”.—[Official Report, 10/2/14; col. 419.]
However, can he comment on the plans expressed by the Home Office Permanent Secretary to extend the Home Office “radar”, as he puts it, into the NHS? The Minister has sought to portray the Bill as making little difference to the accessibility of healthcare. That picture is profoundly flawed. The Bill significantly extends, by Clause 34, those migrants who may be charged for healthcare. The healthcare services for which this wider group of migrants may be charged are also to be greatly extended. To implement this, and the migrant levy in Clause 33, the Department of Health and the Home Office are working on a registration system to be applied throughout the health system. I refer noble Lords to page 18 of the Department of Health’s Visitor and Migrant NHS Cost Recovery Programme: Sustaining Services, Ensuring Fairness in the NHS. Will the Minister comment on whether they are working on such a system and what its purpose is?
The proposals can lead only to an increased public health risk—and I have no doubt that we will deal with that at a later stage. Children’s health and wellbeing will be put at greater risk if a parent or family member is not treated for an infectious disease. The people who will be most at risk are the children. The Department of Health accepts the responsibility to provide healthcare to anybody who needs it, but the proposals in the Bill will play against that. The children’s future will also be put at risk if their mothers do not receive any or timely antenatal care. A physically or mentally ill parent may be unable properly to care for his or her child, with health and other safeguarding consequences. Indeed, when children are not attending healthcare services, the risks that safeguarding concerns are missed will be increased. Hence, the Bill runs counter to the Home Secretary’s duty to safeguard and promote the welfare of children. Nor is it consistent with the UK’s general duty that,
“in all actions concerning children, the best interests of the child shall be a primary consideration”.
That is a reference to the 1989 UN Convention on the Rights of the Child. How do the Government feel that they will fulfil this by introducing the proposals in the Bill?
Imposing the health levy and other NHS charges on children and pregnant women for preventive, acute and emergency care will not fulfil the Government’s legal, moral or ethical responsibility for providing care for children, particularly emergency care. They will fail in their commitments to the UN convention. If we do not care for those vulnerable children, particularly the very young, and pregnant mothers, who do we care for? Is it only those who can afford to pay?