28 JUNE 2010 (BY EMAIL ATTACHMENT) NHS OVERSEAS VISITORS

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28 June 2010

(by email attachment)

NHS Overseas Visitors Policy Team

Department of Health

Room 4W04 Quarry House

Quarry Hill

Leeds LS2 7UE

Dear Sir or Madam,

“Review of access to the NHS by foreign nationals”

UKCISA welcomes the opportunity to respond to this consultation.

Background on UKCISA

UKCISA, the UK Council for International Student Affairs, is the national advisory body serving the interests of international students and those who work with them.

It has some 550 institutional members including all UK universities, the majority of higher and further education colleges which are active internationally and a range of specialist and representative bodies. Our Chair is Professor Christine Hallett (Vice Chancellor and Principal, University of Stirling) and our President is Baroness Usha Prashar (Chair, Judicial Appointments Commission).

International students contribute an estimated £8.5 billion to the UK’s economy. Furthermore, international students studying in the UK bring massive benefits in terms of the UK’s cultural, trade and political influence globally. It is in that context that we would urge the government not to impose any additional requirements on them with regard to either health insurance or immigration penalties, especially in the absence of any evidence of significant or substantial use, or abuse, of the NHS by this group.

Chapter 5 of the consultation: health insurance

Chapter 5 of the consultation outlines three alternative proposals for introducing a requirement for migrants to hold health insurance involving:

(i) compulsory health insurance; or

(ii) recommended insurance – possibly extended to include NHS services within the ‘public funds’ definition in the Immigration Rules; or

(iii) making take up of health insurance a condition of course registration through the educational institution.

On page 26, the consultation document outlines what UKCISA believe to be very realistic difficulties with introducing a requirement for migrants to have health insurance:

“the insurance market is not well-developed in some countries, although it may encourage the development of new insurance products”

Given that the insurance market is not well-developed in some countries, any measures to introduce a health insurance requirement in any of the three proposals would have an immediate negative impact for international students from those countries. It may in the longer term encourage the development of new insurance products in those countries, but it may well be unscrupulous providers who make their products available earlier than those who might develop insurance products that genuinely meet the relevant needs.

“insurers would wish to make individual checks on pre-existing disease and may base premiums on personalised risks, effectively preventing travel by those with a poor health record, including elderly family visitors”

Those with a poor health record could, effectively, be prevented from travelling due to strict requirements imposed by insurance companies. This would have a negative effect on students where their family members might be unable to visit or attend their son or daughter’s graduation ceremony. It could also prevent disabled students from taking courses in the UK, or at least discriminate against them by making their application costs much higher than those of other students.

“it could act as a deterrent to people coming here to visit, work or study with potential economic impacts. It may have a disproportionate impact on certain groups, raising equality and discrimination issues”

As mentioned above, the risk to the UK’s economy would be significant. Any such deterrent would be disproportionate - the risk to this crucial UK export (international education), which brings more than just its substantial financial benefits, would not be offset by the money saved for the NHS (which would itself be burdened with having to assess all aspects of unfamiliar insurance schemes and need to engage with complex immigration issues at a sophisticated level).

“difficulties in assessing the validity and/or adequacy of insurance documents and the associated risk of forgeries”

Assessing the validity and/or adequacy of insurance documents, and the associated risk of forgeries, would impose a heavy and expensive administrative burden on NHS staff, UKBA staff and UK’s educational institutions. The need for new lines of communication between all of these parties would require massive resources and would, no doubt, be vulnerable to serious errors. And each of these parties is already labouring under hefty bureaucratic burdens.

“increased delays as consulate and UKBA officers assess the adequacy of each health insurance policy”

International students usually have limited time between exam results and the start date of their next course. And, anyway, they are not permitted to make their Tier 4 immigration application more than 3 months before the start date of the relevant course. Given that there are already unavoidable delays built into the application process, such as processing the application fee, capturing biometrics and, for some, obtaining an Academic Technology Approval Scheme (ATAS) certificate, any additional delay incurred due to assessing the adequacy of each policy would place unwelcome pressure on consulate and UKBA staff and would doubtless result in many international students missing their course start date.

“potential difficulties of verifying insurance and applying charges for the NHS”

We would agree that such difficulties would be likely and, therefore, it would appear to be impractical for NHS staff to have to deal with verifying insurance and applying charges in addition to the administrative checks that they already have to undertake.

“non-visa visitors would have to be assessed at entry ports, leading to delays, but exempting non-visa visitors may be unfair and discriminatory”

We would agree that delays at ports would result if non-visa nationals had to be assessed for adequate health insurance and this would affect those coming to the UK as student visitors from non-visa national countries. We appreciate that exempting non-visa visitors might be unfair and discriminatory and would therefore recommend for this, and the above reasons, that any requirement to have health insurance should not be introduced.

NHS as a ‘public fund’ in the Immigration Rules

With regard to the ‘recommended insurance’ proposal specifically, we would strongly urge against any review of the exclusion of NHS services from ‘public funds’. As you imply in the consultation, any inclusion would be complicated by the need to reflect exemptions relating to reciprocal agreements, infectious diseases and identified categories of visitor, and to safeguard the provision of urgent treatment. It would add a requirement for NHS professionals to become immigration specialists. Again, without evidence, we feel that to introduce this requirement would, with specific regard for students and their dependants, be an overly burdensome step for both NHS and UKBA.

It would not, therefore, appear to be a light touch approach and:

either would introduce large areas of ambiguity at the point where a sick or injured person required health treatment
or would necessitate access to NHS regulations similar in complexity to those that currently exist in the regulations for welfare benefits and council housing
would increase spending on NHS administration at a time when budgets are particularly tight and priority should be given to treatment – there is no indication in the consultation document of the amount of money that such provision would be likely to save, so we can only assume that increased staffing for this would not be cost effective.

Educational institutions imposing health insurance as a condition of acceptance

As regards the third proposal (making health insurance a condition imposed by educational institutions on acceptance for courses), this would effectively shift the unworkable set of difficulties at page 26 of the consultation, as discussed above, on to those institutions. This would be grossly unfair and inappropriate for institutions who, as Tier 4 sponsors, have already taken on hugely expensive, time-consuming and, sadly, confusing duties in their newly developing partnership with the UKBA.

Access to health care and fear about its effects on immigration status

In addition to the above, any health insurance requirements linked with immigration requirement and/or immigration conditions would inevitably lead to confusion for decision makers in the NHS and UKBA as well as for international students and their institutions. For international students themselves, they would also be vulnerable to fears for their continued or future immigration status which could prevent them from accessing essential health care, including at an appropriately early stage of any illness or injury. In some cases this might have an adverse impact on the health of the wider host community.

Asylum seekers and unaccompanied children

UKCISA would agree with the proposals summarised in questions 5 and 6 to exempt from charges asylum seekers under section 4 and section 95 and unaccompanied children. Not going ahead with either of these proposals would, we feel, place the government in a position where it was not complying with the humane approach required by natural justice.

NHS debtors

The UKBA’s consultation on refusing entry or stay to NHS debtors is linked with this NHS consultation. UKCISA will, therefore, copy this response to UKBA along with our response to their consultation.

On the subject of NHS debtors, we are not aware of any systematic and prolific abuse by students, or their dependants, of NHS resources. The consultation does not provide any evidence that international students prove to be a large contributor to NHS debt.

Furthermore, if any immigration penalties were introduced for NHS debtors, we would urge the government to ensure that international students who inadvertently become overstayers should not be penalised. There has been an increase in occurrences of this since the introduction of Tier 4 of the Points Based System where applications for extensions of immigration leave are rejected, often after a long delay, as if those applications had never been made due to a relatively minor error in the application form or the evidence provided. Subsequently, such applications are usually dealt with successfully. But the student may well in the meantime have been an overstayer, albeit tolerated by UKBA, and sometimes only retroactively when the applicant is informed of their rejected application a considerable time after their leave expired. If the student had been in receipt of NHS services during that time, it would be unfair and disproportionate for them to be found to be liable for NHS charges and then, if unable to pay, to be classed as a NHS debtor and face removal from the UK with a time ban on being able to return to the UK to complete their studies.

Thank you for your attention. Please do not hesitate to contact us if you require any further information. If helpful, we would be very happy to meet with you to discuss our concerns.

Yours sincerely,

Duncan Lane

Director of Advice & Training, UKCISA

[email protected]

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