My Lords, I shall speak to Amendment 66A on behalf of the noble Baroness, Lady Masham of Ilton, who sadly has another commitment that she has to honour this evening. Successive Governments have very good track records in safeguarding the public’s health. When I was a Minister, I was deeply involved in the Health of the Nation strategy, which was lauded at the time by the World Health Organisation as a model for other countries to follow. Since then, through the Labour Government and now our present Government, we have concentrated on looking after the public’s health. Indeed, Ministers were saying only in November last year that nothing will be done to worsen public health. Two years ago, this Government extended free treatment regardless of immigration status to include treatment for HIV infection. As was said at the time:
“Reducing transmission will reduce the risk of new infections in the wider UK population and … reduce … NHS costs”.—[Official Report, 29/2/12; col. 1397.]
They have confirmed that treatment for communicable diseases and sexually transmitted infections will remain free to all.
These are really welcome and important commitments but we have to be very careful that this proud record is not undermined by what we are now doing. Many noble Lords, I know, have a crystal-clear understanding of the Bill, as the noble Baroness, Lady Meacher, has explained to us this evening, but I would like to clarify some issues. First, who is actually going to be affected by these charges? I look to my noble friend to provide the clarity that I seek.
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Clause 34 means that non-EEA migrants without permanent residence will be liable for NHS charges. That is clear. Under Clause 33, migrants on student, worker and family visas will remain entitled to free NHS services by paying the charge with their visa applications. That is clear, but it includes a power to exempt some groups from this charge. I want to know whether those groups that are exempted from the charge will also be exempted from all NHS charges or whether they must pay for NHS services. It is clear that visitors will not pay the charge, but they will pay for NHS services. However, those who require a visa, but do not have one, will also pay for those services. That includes people who stay beyond the expiry of their visa and those who entered without one. Visitors, overstayers and those entering without a visa are of course already liable for NHS charges. There will continue to be exemptions for asylum seekers and those formally recognised as victims of trafficking. Those granted refugee status or humanitarian protection will also be exempted from charges.
I very much welcome these exceptions but I presume that those refused asylum will face charges, as will most victims of trafficking who are not recognised through the national referral mechanism, including many who are still being exploited. In the debate on Monday, it was said that the children of those liable for NHS charges will also not get free NHS treatment. Then there are those who come on a visa, with which they paid the charge, and who are later refused an extension of that visa. Will they still get free NHS treatment while waiting for an administrative review decision? What if the period for which they paid the charge has already expired? What if their review is refused and they bring a human rights appeal? There are concerns that Schedule 9 removes the protections that appellants have currently to be treated as lawfully resident while their appeal is considered. Are those concerns correct? In any case, will NHS treatment be free during their appeal?
Subject to this last matter, it may seem nothing very much is changing, but I do not think that is the case. Primary care and accident and emergency treatment are currently free to all but, in future, those I have identified will have to pay for them. This Government made HIV treatment freely available because they recognised that,
“late diagnosis results in increased mortality and morbidity and more expensive treatment”.—[Official Report, 29/2/12; col. 1397.]
That does not apply just for HIV but to any injury or illness. Public Health England advises that approximately 70% of HIV, TB and malaria cases are diagnosed in people born abroad and points to economic disadvantage and overcrowded living conditions as factors increasing the risk of infection. Undocumented migrants and refused asylum seekers will be disproportionately represented among these at-risk groups.
Not engaging with NHS services, particularly primary care, will exacerbate the risk of undiagnosed infection, but introducing charges for primary care will deter people from doing so. GP consultations will remain free but what, if any, treatment will the GP be permitted to provide without charging? I think other noble Lords have raised that point. If the GP cannot provide free treatment, there is no incentive for someone who cannot afford to pay to attend. The Royal College of General Practitioners has warned that most people who are ill,
“from infectious diseases do not know what is making them ill”.
I am sure my noble friend will agree that permitting free treatment for infectious diseases is inadequate if infection remains undiagnosed or people do not know what is making them ill. If infections are to be diagnosed, it is vital that people engage with primary care, including GPs. If children are to receive immunisations, it is vital that their families engage. Amendment 66A, in the name of the noble Baroness, Lady Masham, would help to encourage that engagement. We believe that charging would deter engagement, putting public health at risk. We also believe that it would not be cost-effective to impose and seek to recover a charge.
Ministers have made clear that they,
“will never refuse urgent or necessary treatment to somebody because they cannot pay for it”.—[Official Report, Commons, Immigration Bill Committee, 7/11/13; col. 303.]
That is welcome. However, early and preventive treatment is better before urgent and much more expensive treatment becomes necessary. One straightforward example concerns a refused asylum seeker in Northern Ireland who suffered from asthma. For want of an inhaler, her health deteriorated. She was admitted to an intensive care unit and hospitalised for several days. For want of a few pounds, she eventually required treatment costing thousands of pounds. This caused her unnecessary suffering and substantial unnecessary cost to the Northern Ireland health service. Amendment 66A would address this. If the cost of treatment falls below a level set by the Secretary of State for Health, there would be no charge, saving the NHS money in the long run and, again, encouraging people to engage with primary care.
I want to raise one final matter. The Home Office Permanent Secretary told the Home Affairs Select Committee that the Home Office intends,
“to improve our radar screen into the health service”,
to identify people for immigration enforcement purposes. At Second Reading my noble friend assured the House that GPs will not become immigration officers, and I think he reiterated that on Monday evening when we were debating the pregnancy issues. GPs and other healthcare providers will have to check whether a person is eligible for free treatment. If this involves bringing someone to the attention of the Home Office, I fear that many people will not seek treatment. Already, around one in five service users attending the Doctors of the World clinic in east London has not attempted to access healthcare for fear of being arrested or reported. That includes many of the people about whom concerns are being raised in these amendments.
If the Government are to make good their commitment to protect public health, plans to extend the Home Office radar screen in this way should be reconsidered. I hope my noble friend will do that and perhaps not pursue these plans. I look forward to his reply.