My Lords, Amendment 52 is to do with public health protection. In Committee, the noble Baroness, Lady Cumberlege, spoke to this amendment, for which I was very grateful as unfortunately I had a long-standing commitment which I had to attend. The noble Baroness, like me, is passionate about health safety and knows that the Bill may cause danger to the health of the nation. Some people who have not paid the health levy may not seek help when they become ill because they fear being reported to the authorities and they may not have the money for tests and medication.
I am particularly concerned because, with the resistance to antibiotics and antivirals, diseases may be spread when people leave treatment too late. If they think they have to pay for medication, they will not go to primary healthcare for diagnosis. What will be the point?
As it is, it is very difficult to find some homeless people who need screening and I congratulate the organisation Find and Treat. I thank both Ministers for the recent meeting we had with the noble Lord, Lord Taylor of Holbeach, and the noble Earl, Lord Howe. It is important that departments work together over this complex matter with Public Health England. This amendment is to do with public health and cost-effectiveness.
I declare an interest as an officer of the APPG on Primary Care and Public Health and the groups on HIV and tuberculosis.
The purpose of the amendment is to provide an exemption from NHS charges where the cost of imposing and recovering a charge is not cost-effective or where the imposition of a charge constitutes a risk to public health. Doctors of the World supports this amendment, as do other health organisations.
In its response to last year’s consultation, the Royal College of General Practitioners made clear that it,
“opposes any change to the eligibility rules for migrants accessing GP services”.
Among the reasons given for its opposition were risks to public health and the imposition of new administrative burdens. Dr Mark Porter, the chair of the BMA council, has described the proposed charges as, “impractical, uneconomic and inefficient”. The Academy of Medical Royal Colleges emphasised in its response to the consultation that any proposals adopted,
“should not … create a bureaucratic process and burden that outweighs any tangible benefits”.
The amendment does not prevent charging but provides some flexibility within the proposed system to make it more cost-effective. The requirement to set a,
“minimum threshold of service cost”,
introduced in proposed new subsections (2) and (3) of Section 182 of the National Health Service Act 2006, achieves this. It requires the Secretary of State to stipulate a figure in regulations. If the cost of providing primary care falls below the stipulated figure, there is to be no charge. Similarly, if the provider of primary care considers that it will not be cost-effective to recover the charge, the provider may waive the charge. This would be achieved by the amendment in proposed new subsection (4) to Section 182 of the National Health Service Act 2006. Section 182 concerns exemptions from charges, including NHS charges to be made under Section 175, to which Clause 34(2) of the Bill refers. To this extent, the amendment responds to the concerns of the Royal College of General Practitioners, the BMA council and the Academy of Medical Royal Colleges. The Department of Health has acknowledged that,
“the administrative cost may outweigh the recoverable charges for frequently used but relatively inexpensive services”.
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The amendment would be limited to primary care, because in this setting the provision of healthcare is most likely to raise questions about the cost-effectiveness of imposing and seeking to recover a charge. Discrete
secondary care interventions are likely to be generally more expensive. At a Commons Bill Committee, the then Immigration Minister, Mark Harper MP, said,
“we will not do anything that will worsen public health”.—[Official Report, Commons, Immigration Public Bill Committee, 12/11/13; col. 310.]
Of course it is important for those who are in the UK, even if they are not here legally, to have access to public health treatment because it has an impact, not just on them but on the rest of the community. That is well understood by both the Home Office and the Department of Health. However, the Bill, and the charges for which it is intended to pave the way, will worsen public health.
The Bill extends the range of migrants who may be liable for NHS charges. Currently, those who are living in the UK lawfully for settled purposes as part of the regular order of their life have free access to NHS services. Clause 34 will mean that all non-European Economic Area migrants who do not have indefinite leave to enter or remain—that is, permanent residence—will be liable for NHS charges. The Government further intend to greatly extend the range of NHS services to which these charges apply.
Currently, primary care as accident and emergency treatment is free of charge. The Government are to introduce charging for primary care as accident and emergency treatment, although GP consultations are to remain free. It appears that any treatment that the GP may provide further to that consultation will be charged for. This is to contribute to the hostile environment that the Home Secretary says the Bill is intended to create for undocumented migrants. However, if undocumented migrants, including victims of human trafficking and refused asylum seekers, are to be charged for any treatment that they may need following a GP consultation, it seems highly unlikely that many of them will attend a GP. What will be the point if they cannot pay for any treatment that they may need?
As the RCGP emphasised in its response to the consultation,
“diagnosis of infectious disease is a core activity of general practice”.
The Department of Health has acknowledged this. The Government have committed to retaining free treatment for the specified communicable and sexually transmitted diseases but, as the RCGP said, often people suffering from infectious diseases do not know what is making them ill. It is likely that a significant number of individuals will be deterred from presenting at their GP practice for fear of charges and/or eligibility checks.
Similarly, we are concerned that limiting access to primary care would impact detrimentally on immunisation rates, as it would be more difficult to encourage presentation by parents from non-eligible migrant groups. We note that the royal college is right to be concerned about eligibility checks, particularly given the intention of the Home Office to extend its radar into the NHS via these checks, as revealed by the Home Office Permanent Secretary last year. That matter is not addressed by the amendment. However, the amendment would mitigate the potential deterrent effect of NHS charging by permitting a primary care provider to waive
a fee where to do so is necessary on public health grounds. This would be included in proposed new subsection (4) to Section 182, referred to earlier. This would provide some amelioration of the concerns of the Academy of Medical Royal Colleges and the Royal College of Psychiatrists. It says:
“Although we welcome the statement that there should be exemptions from charging in respect of infectious diseases including all”,
sexually transmitted infections,
“we are concerned about the potential effect of the proposed legislation on migrants with mental health problems and/or those with developmental disorders and intellectual disabilities. There is a strong public health case for considering the needs of these vulnerable groups when making decisions about charging exemptions”.
The amendment would also permit a GP to waive a fee to treat a condition where the likely result of not doing so was that the condition would deteriorate to a point where urgent and much more expensive treatment became necessary. The NHS gains no advantage from not doing this, since the person who cannot pay for an early and relatively inexpensive intervention will be no better placed to pay for a later and very expensive one. An example was given by the Northern Ireland Law Centre in its June 2013 policy briefing of an asylum seeker who required an inhaler due to her asthma. When she was refused asylum she found herself excluded from healthcare, and without an inhaler her condition deteriorated so far that she was admitted to an intensive care unit and remained in hospital for five days. I beg to move.