The Immigration Bill: Extending charging regimes and scapegoating the vulnerable will pose risks to public health

In March 2014, the Immigration Bill 2013–14 received a comprehensive, line-by-line reading in the Committee Stage before its final reading in the House of Lords. ¹ The Bill is far reaching and, if passed un-amended, will alter access costs of accessing to the NHS for visitors and temporary migrants from outside the European Economic Area (non-EEA). Crucially, the Bill confers on the Secretary of State a wide-ranging discretion to implement a charge – a ‘migrant health levy’ – on immigrants seeking entry or leave to remain for a limited period to access healthcare. ² This applies irrespective of whether the migrant holds insurance, or accesses NHS service during his or her stay. The Bill also refers to existing charging provisions, providing a legal basis for greater scope in charging for NHS services. Such charging, while not specified in the Bill, was recently expanded by the Department of Health, and is proposed to apply to any non-EEA visitor who does not fall into one of a handful of exemption categories, vaguely detailed in the Department's announcement. ²

Politicians claim these measures are necessary to cut costs of ‘health tourism’ and ‘abuse’ by illegal immigrants, and to further the Government's push to reduce net migration overall. However, the evidence shows that the UK is a net beneficiary of health tourism ³ and that, while immigrants account for 4.5% of the population in England, they are responsible for less than of 2% of NHS expenditure. ⁴ Currently, non-EEA migrants contribute 2% more in taxes than is spent on them, making them net contributors to the UK. ⁴ But mounting evidence from countries such as Spain ⁵ and the USA ⁶ highlights the problems this could cause for doctors and patients.

First, the Immigration Bill will create a substantial administrative burden for NHS staff. ⁷ They will be required to act as immigration officials, ascertaining their patients’ eligibility when providing treatment. ⁸ The Department of Health's own figures suggest that the cost of implementing the Bill may outweigh any potential savings. ² NHS providers will have to implement expensive new accounting and information-sharing platforms linked to the Home Office, with neither NHS nor Home Office having a strong track record of implementing major information systems. This will be an additional cost at a time when many providers are already facing severe financial pressures, ⁹ and in the face of growing public concern over data sharing.

The Bill will also make it more difficult to appoint and retain NHS staff. For instance, the General Medical Council registration data indicate that 36% of all registered doctors qualified outside the UK, with 26% of all doctors being non-EEA qualified. ¹⁰ Migrant workers serve especially important roles in services facing recruitment problems, such as Accident and Emergency departments and community and social care for older populations. Anything that drives away professional migrants will further worsen an already alarming staffing situation in these areas; a problem that is now being exacerbated by increasing emigration of British-trained staff to countries such as Australia to take advantage of more attractive working conditions. ¹¹

The Bill also poses wider threats to the health of both migrants and the established population. ⁷ Migrants coming to the UK are generally in good health, but over time they face increased risk of non-communicable diseases, such as cancer and diabetes mellitus. ¹² European studies have found that migrants to the UK utilise screening programmes and primary care less than locally born individuals. ¹³ The failure to intervene early gives rise to worse outcomes for many conditions, and higher long-term costs to the NHS. Some migrants may have communicable diseases which, if untreated, may pose a threat to the established population. Furthermore, additional eligibility checks and reporting requirements will further detract from patient care at a time when there are already concerns about staff shortages.

If the Immigration Bill is likely to increase costs, worsen staffing issues, and pose threats to public health, then why are politicians pursuing it?

The Bill can only be understood in its political context. Most obviously, the Conservative Party is concerned about loss of support to the United Kingdom Independence Party and believes that it must be seen to appear tough on migration in the lead up to the 2015 General Election. The Bill sends out a clear signal to its supporters, in effect reiterating the message conveyed by the Home Office’s egregious ‘Go Home’ immigration vans, that migrants are not welcome here. The Bill targets a vulnerable and easily scapegoated group – migrants – but who will be the next focus of expanded NHS charges? Edmund Burke said when ‘bad men combine, the good must associate'. If we do not oppose the targeting of the most vulnerable in our country ‘we will all fall one by one'. ¹⁴