The Immigration Act. A briefing by Doctors of the World UK for local Healthwatch November Key points. Contents

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1 The Immigration Act A briefing by Doctors of the World UK for local Healthwatch November 2014 Key points Although healthcare is free for the vast majority of people, there are some groups who are required to pay for some of their treatment. These charges have been introduced over time, mainly in response to fears about abuse of the NHS by health tourists It is important to distinguish between individuals who primarily travel to the UK for healthcare compared to those who are vulnerable refugees, asylum seekers, or who have come to work or to be with family. There is very little evidence supporting claims of health tourism to the UK. Charges for NHS treatment currently apply to undocumented migrants and people in the UK as visitors. Although there are some specific exemptions for particular groups. Charges for NHS treatment for chargeable groups do not apply to all services and treatment for example all primary care services are free for everyone. Charges mainly apply for some secondary care treatments provided in a hospital or by a hospital although some services in hospital are still free to all. Key changes under the Immigration Act 2014 include: Expanding the types of groups of people who are liable for charges for healthcare to include any migrant who does not have permanent residence unless they are exercising European free movement rights. Introducing a new Healthcare Levy for migrants - a charge which, once paid, will cover the costs of NHS healthcare for that person during their stay. Introducing new provisions which would require private landlords to carry out immigration status checks on potential tenants to make sure that they are entitled to be in the country. Contents 1. Introduction The myths around health tourism The current situation... 2 Who is required to pay for healthcare?... 2 What do they need to pay for? The Immigration Act 2014: Changes made... 3 New groups eligible for health charges... 3 The Healthcare Levy... 4 New Immigration checks by private landlords Other changes to healthcare charges... 4 Expanding the types of NHS services that charges apply to Working locally Sources of more information... 6 The Immigration Act

2 1. Introduction When the NHS was formed in 1948 it was based on the ideal that good healthcare should be available to all, that it would meet the needs of everyone and be free at the point of delivery 1. Whilst this continues to be the case for the vast majority of people in England, over the years charges for healthcare have been introduced for certain groups. The first of these was in 1982 with the introduction of charges for hospital treatment for visitors to the UK. In subsequent years the types of groups eligible for charges and the types of services that attract charges have been expanded. For example, in 2004 the UK Government restricted access to healthcare for refused asylum seekers. There has been significant debate about policies that restrict access to healthcare for migrants, largely focussed on the Government s justification for these policies namely in response to perceived abuse of the NHS and the beliefs around health tourism in the UK. Debate has also covered the UK s obligations under international law, inconsistencies with domestic legislation, and other ethical concerns - not least the basic duties of a doctor. The healthcare of migrants is an emotive and politicised issue, often illustrated by the high levels of, usually negative, media coverage. 2. The myths around health tourism Much of the government and public rhetoric around limiting healthcare for migrants is related to protecting the NHS against perceived abuse from healthcare tourists. However, it is important to distinguish between individuals who primarily travel to the UK for healthcare compared to those who are vulnerable refugees, asylum seekers, and those who have come to work or to be with family. As highlighted in a recent Demos report, someone who is already in the country and then becomes ill and needs help is not comparable legally or morally to an individual who travels to the UK with the intention of defrauding the NHS 2. There is very little evidence of health tourism to the UK, and the Government s own research concluded that estimates of its prevalence were speculative 3. Over seven years, evidence from the London clinic of Doctors of the World UK which serves vulnerable migrants found that, on average, people had been living in the UK for four years before trying to access healthcare, and in just 1 per cent of cases was health amongst the reasons why they left their home country. Furthermore, research by the Medecins du Monde European network found no correlation between the accessibility of a country s healthcare system and migration patterns The current situation Who is required to pay for healthcare? NHS charges for treatment currently apply to people who are in the UK as visitors a and those who are here unlawfully (undocumented migrants). However, within these broad groups there are some specific categories of people who are exempt from charges, including: asylum-seekers; refugees (i.e. those granted permission to stay following an asylum claim); children in local authority care; a Migrants who have permission to be in the UK for more than six months are generally taken not to be visiting The Immigration Act

3 prisoners and immigration detainees; people exercising European free movement rights (the NHS may recover costs of treating many of these people from the European State of their nationality); and victims of human trafficking (but only if they have been officially recognised as a victim or possible victim through the National Referral Mechanism). What do they need to pay for? Charges for NHS healthcare for chargeable groups do not apply to all services and treatment for example all primary care services such as GP consultations - are free for everyone. Charging mainly applies for some secondary care treatments provided in a hospital or by a hospital although some services in hospital are still free to all, namely: Accident and Emergency (A&E) services (unless someone is admitted as an in-patient or if he or she attends A&E by appointment); Family planning services; Treatment for specific communicable diseases and sexually transmitted infections such as HIV or TB. In addition, any treatment which is considered to be urgent or immediately necessary by clinicians, although still chargeable, should be provided without waiting for payment or even a deposit b. This includes all maternity treatment. 4. The Immigration Act 2014: Changes made Access to healthcare for visitors and migrants is a rapidly changing area of Government policy and the latest changes have been introduced within the Immigration Act The government have described that they want to create a hostile environment for undocumented migrants and limiting access to services is part of this strategy. When the Immigration Bill was laid before the House of Commons in October 2013, Immigration Minister Mark Harper said The Immigration Bill will stop migrants abusing public services to which they are not entitled, reduce the pull factors which draw illegal immigrants to the UK and make it easier to remove people who should not be here. New groups eligible for health charges The Immigration Act has expanded the types of groups of people who are liable for charges for healthcare. Under the Act, any migrant who does not have a right to permanent residence c in the UK will be liable for the costs of the relevant NHS treatments (apart from those who are exercising European free movement rights). This will become effective alongside the implementation of the healthcare levy (see below). Groups that are now liable for charges who previously were not include those on a student visa, a workers visa, family members who come to join people already living in the UK, or migrants already living in the UK who switch to a form of temporary leave d. b Failure to do so may be unlawful under the Human Rights Act c Persons who have unlimited leave to remain in the UK and are free from immigration control are known as permanent residents of the United Kingdom. For foreign nationals to become a UK permanent resident they need to apply for permission to settle in the UK also known as indefinite leave to remain (ILR). ILR gives a person the freedom to live and work in the UK without any restriction. They also have access to public funds, such as job seekers allowances and other benefits which are usually available to UK citizens. d A migrant with temporary leave is a non-eea migrant who is subject to immigration control and who does not have Indefinite Leave to Remain. This does not include short-term visitors. The Immigration Act

4 The Healthcare Levy The Act has also given the power to the Home Secretary to introduce a Healthcare Levy for migrants, expected to be introduced in spring The Healthcare Levy is a charge which, once paid, will cover the costs of NHS healthcare for that person during their stay. People who apply for permission to come to or stay in the UK for more than six months to study, to work, or to be with family, will need to pay the Healthcare Levy upfront when they complete the immigration application. The amount is currently set at 150 per year for students, and 200 per year for others but this may change. For example, a student applying for a three year student visa will need to pay 450 Healthcare Levy, in addition to their visa application fee e. New Immigration checks by private landlords The Act contains provisions which would require private landlords to carry out simple checks on people who want to rent accommodation, to make sure that they are entitled to be in the country 5. The aim of the measure, along with many other provisions in the Act is to discourage those who intend to stay illegally or encourage those who are here illegally to leave 6. If implemented, this will affect a large number of migrants for example research shows that in 2011, 76 per cent of recent migrants were in the private rental sector 7. Private landlords would be required to check the immigration documents of all prospective tenants to show that anyone living in the property has the right to live in the UK f. Those landlords found to be renting to an irregular migrant, where they haven t conducted the required immigration checks, could be fined up to 3000 per irregular migrant tenant. These proposed checks have been strongly opposed by a range of stakeholders for a variety of reasons including: whether it is reasonable to expect landlords to conduct these checks; whether landlords have the ability or resources; and, given that there is no official register of private landlords in the UK, how it will be monitored. There are also significant concerns over discriminatory practice by landlords as, although in theory checks would need to be carried out on all prospective tenants, it is likely that there will be discrimination against those prospective tenants who are asked for proof of residence towards ethnic minorities or any foreign nationals 8. This provision is currently being piloted in a few areas in the West Midlands with a view to being rolled out across the UK over the course of 2015 following an evaluation in the spring Other changes to healthcare charges In addition to the Act, last year the Department of Health consulted on proposals to extend both the services for which charges may be made, and who could be charged. The Home Office separately consulted on much the same proposals. Expanding the types of NHS services that charges apply to Whilst the Immigration Act 2014 did not expand the list of the types of NHS treatment that people who are liable for charges will need to pay for, the Department of Health has separately indicated that it intends to do so. Although the details are still to be decided, the new list of chargeable services could include all A&E services and primary care services. It has not yet decided the full extent of the charges that e The levy will be refunded if the application is refused f Landlords would be supported by an and phone service provided by the Home Office The Immigration Act

5 will be introduced in primary care, but expects to include pharmacy, optical and community care services. The Department of Health has confirmed that some NHS treatment will definitely remain free, including treatment for specific communicable diseases (such as TB), sexually transmitted infections (such as HIV), and GP consultations. However, it is not yet known whether GP practices will be able to conduct diagnostic tests or provide routine or any other treatment for free, or whether any community mental health services will remain free. There will be, as before, exemptions for certain groups, including asylum seekers, refugees and children in local authority care. Other vulnerable groups may be exempted, but the Department has not yet decided how these exemptions will operate. For example, the Department has acknowledged that many victims of human trafficking do not benefit from the current exemption for these victims, but is yet to decide how better to define and identify victims of human trafficking for exemption from charging. Decisions regarding these new changes will not be taken until later in Working locally The new changes brought in by the Immigration Act 2014 will be evaluated over time. There is a significant amount of concern that there may be some unintended consequences to the new policies which could stop vulnerable people from accessing the healthcare that they need, even when legitimately entitled to it. Signposting and supporting the local community When carrying out signposting duties or whilst engaging with local community members, local Healthwatch can play a key role in sharing facts about the rights of individuals to access health services. Page 6 below lists voluntary organisations that you can refer individuals to who will provide additional support in accessing the healthcare they are entitled to. Spotting the invisible Because vulnerable migrants are very much a hidden group, it can be hard to know if there are problems with access to healthcare. Local voluntary organisations working with migrant communities may know of any local concerns and whether they are seeing problems amongst their client groups. When working with commissioners and providers it is valuable to reflect on whether local health plans address the needs of all local community members including migrants. If you are finding problems locally with access to healthcare for individuals or groups who are entitled to services, and you have done all that you can locally to resolve the issue, consider using the Healthwatch escalation process and asking Healthwatch England to look into the issue nationally. Liaising with local health services There is comprehensive guidance produced by the Department of Health for health services to help them to understand when someone is or is not liable for charges for healthcare services. Unfortunately, because this is a complex area, sometimes there is a significant amount of confusion amongst frontline healthcare staff regarding who is eligible for services, and they may not even be aware of the guidance. The Immigration Act

6 7. Sources of more information The Immigration Act 2014 The Immigration Act: Explanatory notes (Part 3: Access to services) Primary care registration guidance NHS London Once for London Pan-London Operating Principles for Primary Care. GP Patient registration nsoperatingprocedures.pdf BMA guidance: Overseas Visitors and Primary care Hospital care charging guidance Department of Health: Guidance on implementing the overseas visitors hospital charging regulations 530/ovs_visitors_guidance_oct13a.pdf Voluntary sector organisations For support with queries regarding individual cases, or for referral for support: Doctors of the World UK National clinic advice line: (Open 10am to 12 midday, Monday-Friday) Outside of these times please Citizens Advice Bureau For detailed briefings on a range of issues around migration: Migrants Rights Network The Immigration Act

7 About Doctors of the World Doctors of the World provides essential medical care to excluded people at home and abroad while fighting for equal access to healthcare worldwide. Through our 3,000 volunteers we help those affected by war, natural disasters, disease, hunger, poverty or exclusion get the healthcare they need regardless of income or status. Whether it s providing mental healthcare to Syrian refugees, vaccinating children in Mali, or delivering babies in the DRC we meet the health needs of vulnerable people across the planet. And where possible, we share our skills and training locally so communities stay strong in the long term. We also work with the most marginalised to report on violence, injustice and healthcare barriers wherever we see them. We are part of the Medecins du Monde global network, which delivers over 300 projects in more than 70 countries. In the UK, we run a clinic and advocacy programme in east London staffed by volunteers who provide medical care, information and practical support to excluded people such as vulnerable migrants, sex workers and people with no fixed address. You can find out more about our work at: References 1 About the NHS: NHS Core Principles. Available online at Accessed November Demos, Do No Harm: Ensuring fair use of the NHS efficiently and effectively 3 Department of Health, December Sustaining services, ensuring fairness: Government response to the consultation on migrant access and financial contribution to NHS provision in England. p80 4 Doctors of the World, Access to Healthcare in Europe in Times of Crisis and rising Xenophobia 5 Home Office, Tackling illegal immigration in privately rented accommodation 6 Home Office, Tackling illegal immigration in privately rented accommodation 7 Migration Observatory, Migrants and Housing in the UK: Experiences and Impacts 8 Migrants Rights Network, The Immigration Bill: Creating a hostile environment for migrants in the UK. MRN briefing paper 9 Home Office, 3 September West Midlands to be first landlord right to rent check area. Available online at Accessed November 2014 The Immigration Act