Controlling Immigration Regulating Migrant Access to Health Services in the UK

Transcription

1 Controlling Immigration Regulating Migrant Access to Health Services in the UK Response from the North West Regional Strategic Migration Partnership 6 th August Should all temporary migrants, and any dependants who accompany them, make a direct contribution to the costs of their healthcare? (Yes / No / Don t know) 1.1 Yes 1.2 We agree with this as a broad approach, as it is consistent with the contributory principle upon which the NHS was founded. We recognise that in the case of most temporary migrants with leave of more than 6 months (comprised mainly of students granted leave under tier 4 of the points based immigration system), there is no guarantee that they will be paying National Insurance contributions during their stay in the UK, and some form of up-front payment may be appropriate. However, we feel the proposed migrant health levy does not take account of the fact that some temporary migrants with leave of more than 6 months will be undertaking paid employment, and therefore paying National Insurance contributions. In such cases, a different approach may be needed. 1.3 The consultation document says the operation of the NHS is governed by a social model that applies the principles of equity and shared risk. Those who can afford it will pay in more than others, and those who have greater health needs are offset by those who remain healthier. (section 4.1) 1.4 In terms of equity, while temporary migrants paying National Insurance contributions do not necessarily make the same financial contribution to the NHS as permanent residents paying in throughout their working lives, by the same token neither do temporary migrants enjoy a lifelong entitlement to NHS services. Their limited financial contribution is inextricably linked to their limited length of entitlement, and cannot confer any unfair advantage on them. 1.5 In terms of pooled risk with the permanently resident population during this limited period of entitlement, temporary migrants paying National Insurance contributions are by definition economically active people, and it seems unlikely they will be particularly heavy users of NHS services. Therefore, continuing to apply the principle of pooled risk to 1

2 temporary migrants paying National Insurance contributions is unlikely to provide them with an unfair advantage. 1.6 Our proposal is that temporary migrants paying National Insurance contributions should continue to enjoy entitlement to NHS services in keeping with the contributory principle upon which the welfare state was founded. In cases where there is no guarantee that National Insurance contributions will be paid, such as students and family migrants, we propose a one-off, up-front contribution into the National Insurance NHS allocation, supported by the creation of a new class of National Insurance contribution for non-employed temporary migrants. 1.7 This should be accompanied by a government communications strategy, targeting both prospective migrants and the general public, making clear that this is a one-off, up-front National Insurance contribution, incorporated within the existing system, and that we are not introducing a parallel system for temporary migrants. This should help to mitigate the risk that prospective migrants feel they are being singled out and deterred from coming to the UK; and also reassure the general public that temporary migrants are accessing NHS services on the same terms as anyone else. 2. Should access to free NHS services for non-eea migrants be based on whether they have permanent residence in the UK? (Yes / No / Don t know) 2.1 No 2.2 As noted above, access to NHS services is not free if National Insurance contributions are paid, and those who pay into the system may reasonably expect some benefit in return, irrespective of residency status. Instead of changing the residency test, we propose that access to NHS services for temporary migrants with leave of more than 6 months should be based on whether they pay National Insurance contributions. This could either be deducted at source from the pay of economically active people, or a one-off, up-front contribution for people for whom there is no guarantee they will be paying National Insurance contributions during their stay in the UK. 2.3 We welcome the proposal to maintain exemptions to any new residency test for recognised refugees, asylum seekers, refused asylum seekers in receipt of either section 4 or section 95 support, children in Local Authority care and victims (and suspected victims) of trafficking. We would welcome clarification that people granted Humanitarian Protection or Discretionary Leave to Remain will continue to be exempted. 2.4 We welcome the proposal to maintain exemptions on public health grounds, eg treatment for tuberculosis and sexually transmitted 2

3 diseases. However, we have some concerns relating to the public health impact of introducing primary care charges for people such as unsupported refused asylum seekers and illegal immigrants who do not have the alternative of health insurance. 2.5 For example, the National Aids Trust (NAT) has argued that the introduction of primary care charges based on residency status will undermine efforts to detect and treat undiagnosed HIV in migrant communities, among whom the crisis of undiagnosed and latediagnosed HIV is more severe than in the rest of the population. Evidence shows that compared to the rest of the population, people in this group are much more likely to be diagnosed with HIV in a GP surgery or hospital than in a sexual health clinic. NAT argues, therefore, that reducing migrants access to primary care will keep them away from one of the settings most likely to encourage them to test for HIV. 1 This is likely to have negative consequences both for their own health and in terms of onward transmission. In terms of cost to the public purse, one admission to intensive care for a patient with HIV-related pneumonia can cost as much as two years of antiretroviral treatment TB Alert has also argued that introducing primary care charges could unwittingly damage the health of the wider population. They say that for infectious diseases such as tuberculosis, discouraging people from accessing primary care will lead to them arriving at A&E when their symptoms are advanced, and only after they are likely to have infected other people A requirement to hold health insurance should help to reduce this barrier to primary care for short-term visa applicants. However, this is clearly not an option for unsupported refused asylum seekers and illegal migrants. We would like to recommend, therefore, that for reasons of public health, the exemption for supported refused asylum seekers should be extended to all refused asylum seekers. In terms of illegal migrants, even though wariness of the authorities may lead to a lower uptake of primary care for non-urgent reasons, there still remains 1 Universal access to primary care: A gateway for HIV testing, treatment and prevention, National Aids Trust, November New developments in sexual health and HIV/AIDS policy, third report of session , volume 1, pp House of Commons Health Committee, Charging migrants to access NHS treatment risks increasing TB in the UK, TB Alert news article, 3 rd July

4 a risk that a gateway for treatment for more serious conditions than those initially presenting will be closed. 2.8 We would welcome confirmation that exemptions will be maintained for treatment provided in Accident and Emergency Departments, compulsory mental health treatment and flu immunisations for at-risk people. 2.9 Finally, we would like to suggest that an exemption is also granted for people accessing the Destitute Domestic Violence concession. This would ensure access to NHS services remains consistent with the general principle of allowing recourse to public funds during the 3- month limited leave period granted under the DDV concession. 3. What would be the most effective means of ensuring temporary migrants make a financial contribution to public health services? a) A health levy paid as part of the entry clearance process b) Health insurance c) Other option (please detail your proposals) 3.1 Other option 3.2 As stated above, some temporary migrants with leave of more than 6 months already make a financial contribution to public health services through National Insurance contributions. The fact that they do not pay in for the whole of their working lives is counterbalanced by the fact that they do not enjoy lifelong entitlement to NHS services, and being in the main economically active, are unlikely to be particularly heavy users of NHS services. For temporary migrants for whom there is no guarantee National Insurance contributions will be paid during their stay in the UK, we propose an up-front, one-off contribution into the National Insurance NHS allocation, supported by the creation of a new class of National Insurance contribution for non-employed temporary migrants. 4. If a health levy were established, at what level should it be set? a) 200 per year b) 500 per year c) Other amount (please specify) 4.1 Other amount 4.2 When setting the amount, account should be taken of the fact that some countries enjoy less favourable exchange rates, for example 1 GBP = appr 28 Ethiopian Birr. In order to guard against the possibility of indirect discrimination, It will be important to set the amount at a level which affected nationalities do not find prohibitive. 4

5 5. Should some or all categories of migrant be granted the flexibility to opt out of paying a migrant health levy, for example where they hold medical insurance for privately provided healthcare? (Yes, some categories / Yes, all categories / No / Don t know) 5.1 Yes, all categories 6. Should a migrant health levy be set at a fixed level for all temporary migrants, or varied (for example according to the age of the migrant)? a) Fixed level b) Varied level c) Don t know 6.1 Fixed level 6.2 In cases where there is no guarantee that National Insurance will be paid, we propose a one-off, up-front contribution at a fixed rate into the National Insurance NHS allocation, supported by the introduction of a new class of National Insurance contribution for non-employed temporary migrants. However, as stated above, migrants already paying National Insurance should be exempted from any levy. 7. Should temporary migrants already in the UK be required to pay a health levy as part of any application to extend their leave? (Yes / No / Don t know) 7.1 Don t know 7.2 If they will be paying National Insurance during the period of their extended leave, then they should not be required to pay any levy. Otherwise, they should be required to pay an extra, one-off, up-front contribution at a fixed rate into the National Insurance NHS allocation, supported by the introduction of a new class of National Insurance contribution for non-employed temporary migrants. 8. Are there any categories of migrant that you believe should be exempt from paying the health levy or other methods of charging (over and above those already exempt on humanitarian grounds or as a result of our international obligations)? (Yes / No / Don t know). If yes, please specify. 8.1 Yes 8.2 As argued above, in addition to the exemptions already specified in the consultation document, we recommend the following categories should be exempted from any levy or other methods of charging: 5

6 People already paying National Insurance People granted Humanitarian Protection or Discretionary Leave to Remain Unsupported refused asylum seekers People granted access to public funds under the Destitution Domestic Violence (DDV) concession People receiving treatment in Accident and Emergency Departments People receiving compulsory mental health treatment At-risk people receiving flu immunisations. 9. Should any requirement to hold health insurance be a mandatory condition of entry to the UK (as determined by the Home Office)? (Yes / No / Don t know) 9.1 Don t know 9.2 Temporary migrants with leave for more than 6 months should not be required to hold health insurance, but if there is no guarantee they will be paying National Insurance contributions during their stay, they should be offered the choice of taking out health insurance (either directly or through their employer/educational establishment) or making a one-off, up-front National Insurance contribution on the principles outlined above. 9.3 Migrants applying for a visitor visa for 6 months or less, however, should be required to hold health insurance as a condition of entry to the UK. This reflects the reality that they will not be paying National Insurance contributions during their short stay in the country, and as they will not be ordinarily resident, a one-off, up-front payment into the National Insurance NHS allocation does not seem appropriate either. Health insurance as a condition of entry for short-term visitors should both help to guard against the risk of health tourism and its cost to the public purse, and also to ensure access to health care for all, with consequent benefits for public health (see paragraphs 2.4 to 2.7, above). 10. Should chargeable migrants pay for all healthcare services, including primary medical care provided by GPs? (Yes / No / Don t know) 10.1 Don t know 10.2 While we accept that introducing charges for those not ordinarily resident is not inherently in breach of the founding principles of the NHS, nevertheless we have a number of concerns regarding the 6

7 possibility of unintended consequences arising from the proposals contained in the consultation document In the case of migrants on a visitor visa of 6 months or less, we only support the proposal to introduce charges for primary care on the condition that visa applicants are required to hold health insurance as a condition of their leave to enter. This seems to be both a more effective way of recovering costs than by pursuing debts, and also helps keep health care in the UK available to all, with consequent benefits to public health (see paragraphs 2.4 to 2.7, above) The question of unsupported refused asylum seekers and illegal migrants is more problematic however, as clearly health insurance is not an option for either of these categories. As argued in paragraphs 2.4 to 2.7 above, we have some concerns over the public health impact of introducing a policy which may deter some people from accessing primary health care, whether through private insurance or the NHS, particularly around HIV and tuberculosis. Therefore, we recommend that the exemption for supported refused asylum seekers should be extended to all refused asylum seekers on public health grounds. In relation to illegal migrants, while we acknowledge there is a strong argument not to provide free health care to people who have sought to bypass the Immigration Rules, our concerns over public health remain. Even though wariness of the authorities may lead to a lower uptake of primary care for non-urgent reasons, there still remains a risk that a gateway for treatment for more serious conditions than those initially presenting will be closed Finally, we would like to emphasise that immediately necessary or urgent treatment for any chargeable category should always be provided, regardless of ability to pay. 7

8 Demographic questions 1. Are you responding as or on behalf of: a. An organisation which represents individuals and groups b. Legal advisor c. NHS Trust d. Health insurance company e. GP f. NHS employee g. Local authority h. Member of the public i. Other (please specify) a. An organisation which represents individuals and groups 2. If an organisation which represents individuals or groups, which of the following does your organisation speak for? a. Migrants b. NHS workers c. Students d. Health insurers e. GPs f. Other (please specify) f. Other (please specify) Regional partnership of over 50 agencies across sectors either providing services to migrants or whose service provision is affected by migration 3. In which part of the UK would the policy on which we are consulting be relevant to you? a. England b. Wales c. Scotland d. Northern Ireland e. none of the above a. England 4. If you are responding as a member of the public, are you: a. A UK citizen b. A citizen of the other European countries or Iceland, Lichtenstein, Norway or Switzerland c. Other N/a 8

9 5. If other, do you have a time limit on your stay in the UK? a. Yes b. No c. Prefer not to say N/a 6. How did you hear about this consultation? a. UK press (national newspapers) b. International press c. Home Office website d. Overseas website e. Word of mouth f. Social networking site g. Other (please specify) c. Home Office website 9

10 Equality questions 1. Please indicate your age. a. Up to 17 years b. 17 to 24 years c. 25 to 44 years d. 45 to 64 years e. Over 65 years f. Prefer not to say Non-applicable as responding on behalf of Partnership 2. Please indicate your ethnic group a. White i. English / Welsh / Scottish / Northern Irish / British ii. White other (please specify) b. Mixed / multiple ethnic groups i. White and Black Caribbean ii. White and Black African iii. White and Asian iv. Any other mixed / multiple ethnic background (please specify) c. Asian i. Indian ii. Pakistani iii. Bangladeshi iv. Chinese v. Any other Asian background (please specify) d. Black / African / Caribbean/ Black British i. African ii. Caribbean iii. Any other Black / African / Caribbean (please specify) e. Other ethnic group i. Arab ii. Any other ethnic group (please specify) f. Prefer not to say Non-applicable as responding on behalf of Partnership 3. Please indicate your sex a. Male b. Female Non-applicable as responding on behalf of Partnership 10

11 4. Do you think these proposals would have any impact, positive or negative, on individuals based on the following protected characteristics Yes / No / Don t know a. Age b. Disability c. Marriage / civil partnership d. Pregnancy e. Race (including nationality, ethnic or national origins or colour) f. Religion or belief g. Gender h. Gender reassignment i. Sexual orientation Yes 5. If you answered yes to any of these, please include any suggestions as to how these impacts might be managed or mitigated. a) In terms of nationality, it is possible the introduction of primary care charges may have a disproportionate negative impact on non-uk nationals, as they are overrepresented in terms of undiagnosed and late-diagnosed HIV: In 2010, half of people newly diagnosed with HIV were diagnosed late, meaning they should already have commenced treatment. When categorised by ethnicity, late diagnosis was highest amongst Africanborn men (66%) and women (61%), followed by Caribbean women (59%) and men (47%). 4 As stated in paragraph 2.5 above, this group is much more likely to be diagnosed in a non-sexual health setting than the rest of the population. Therefore, there is a risk that introducing charges may deter them from accessing primary care, leading to even later diagnoses, with negative consequences both for their own health and for onward transmission. A requirement to hold health insurance should help to reduce this barrier for short-term visa applicants. However, this is clearly not an option for unsupported refused asylum seekers and illegal migrants. Therefore, we recommend that the exemption for supported refused asylum seekers should be extended to all refused asylum seekers. In terms of illegal migrants, even though wariness of the authorities may lead to a lower uptake of primary care for non-urgent reasons, there still remains a risk that a gateway for treatment for more serious conditions than those initially presenting will be closed. 4 Universal access to primary care: A gateway for HIV testing, treatment and prevention, National Aids Trust, November

12 b) Again in terms of nationality, there is a risk that the migrant health levy may indirectly discriminate against nationals of countries with a less favourable exchange rate, for example 1 GBP = appr 28 Ethiopian Birr. It will be important to set the levy at a level which affected nationalities do not find prohibitive. c) It is possible the introduction of a requirement to hold health insurance may result in older and disabled people paying higher premiums. However, we do not view this as discriminatory, as age and disability are used only as indicators of the general statistical likelihood that the policy holder will access health care services, ie there is no inherent link between age and disability and premium levels. John Horgan, Policy and Development Officer North West Regional Strategic Migration Partnership 12