The last amendments to the 2015 Visitor and Migrant Cost-Recovery Program came into force on the 23rd of October. These amendments aim to further reduce the costs attributed to so-called “health tourists”: people who come to England in order to access free healthcare when they are not entitled to it, stretching an already overburdened system.
NHS England provides free healthcare to “ordinarily citizens”: persons who “quite broadly, live in the UK on a lawful and properly settled basis for the time being”.The category is not determined by nationality, national insurance status or having an NHS number, and it can include overseas citizens who are in England on a valid visa and exclude UK immigrants living abroad. Healthcare is also covered for emergency treatment in A&E and at GP practices, regardless of the residence status.
The new regulation enforces this definition by tackling the issue of unpaid care through two separate processes, both of which have been subject to multiple criticisms. On one hand, it asks that frontline medical and non-medical staff determine whether someone is eligible to free healthcare before providing medical treatment. On the other, the regulation requires upfront payment from those who are not entitled to NHS services before any care is provided, billing 150% of the NHS tariff established for a specific treatment.
Prior to this policy, patients not entitled to free healthcare would be invoiced after their treatment was completed, a system that has been argued ineffective in cost-recovery. In turn, findings in cost-recovery after implementing passport checks have been found in the past “very encouraging”, as the Health Secretary, Jeremy Hunt, put it, in returning the cost of treating patients not entitled to free care.
The notion that entitlement to free healthcare is granted to those who contribute (or have contributed, or will contribute) to the social security system is a reasonable one. Untangling the numbers behind this is necessary to understand the impact of the new regulations and analyze its implications full-picture. A government report estimates that the annual cost of foreigners using the NHS is slightly over £2bn. Out of this, according to FullFact (a fact-checking charity), approximately £1.8bn is spent on people who don’t come to the UK to deliberately use the services provided, and is thus non-recoverable. £220 million can be charged to EEA countries, and another £190 million can be recovered directly from patients. This return represents approximately 0.3% of the NHS spending. No estimates have been published on the investment that will be required to implement the new regulations that aspire to recover the full amount.
While cost recovery is necessary, the policies develop for this purpose enhance the Home Office’s measures for the creation of a “hostile environment”, which have characterized the government’s immigration policy since Theresa May took office in 2010. They not only create an unwelcoming environment for migrants and complicate the bureaucratic process that is acquiring leave to remain but, more crucially, push individuals engaging in their everyday duties to enforce the rule of hostility, willingly or not. NHS staff, without having received proper training -if any at all- become a second hand to immigration officers, often falling back into damaging stereotyping and racial profiling, as Docs not Cops has denounced.
The problems associated with these regulations are not only structural: beyond creating a system of hostility, the new guidelines have a potentially devastating impact on individuals who decide not to access care even though they need it, fearing that they will be unable to pay for their care or be reported to the Home Office. A letter delivered to Jeremy Hunt and signed by over 1000 signatories (including organizations and individual healthcare providers) has emphasized “the strong risk that healthcare, including lifesaving care, will be withheld from those unable to prove their entitlement to free NHS treatment or able to pay up-front”, noting that patients living in the UK have already been denied “life saving care such as urgent surgery or cancer treatment because they cannot pay”.
Interferences with visa applications are taken a step further under this scheme. Under current legislation, incurring a debt of more than £500 to the NHS is considered sufficient grounds “on which leave to remain in the United Kingdom should normally be refused”. The fear to accessing health care is enhanced by the fear of being refused a visa altogether, leaving migrants in impossible situations: they can’t work legally, but they need to pay off their debt to potentially be granted the right to work legally.
In the meantime, the NHS is staffed with immigrants, many of them living in a sea of uncertainty over their residence status since the Brexit vote: over 10% of NHS staff is non-British and 5.6% is exclusively EU. The policy is making immigration officers out of individuals who are not sure they will continue to have leave to remain in a year.
The issue at stake is whether the end of recovering the misused funds justifies the means implemented to do so. The policy has the Conservatives’ signature (it was part of the Queen’s Speech last year) and is defended, in words of the Health Secretary, on the line of ensuring migrants and visitors who use the NHS “make a fair contribution, just as the British taxpayer does”.
Although implemented by the Tories, the regulations are bipartisan: they were suggested following the recommendations of the report published by the Committee of Public Accounts, chaired by Meg Hillier of the Labour Party and composed of 15 members, only eight of whom are conservative MPs. Labour’s appearance “to have no formal policy and little to say” regarding this and other issues under the umbrella of a “hostile environment” has also been criticized by Docs not Cops.
Featured image: http://www.geograph.org.uk/photo/4829052