Lords motion to approve the Immigration (Health Charge) (Amendment) Order 2018 - Nov 28

That the draft Order laid before the House on 11 October be approved.

 

Relevant document: 3rd Report from the Secondary Legislation Scrutiny Committee (Sub-Committee A).

My Lords, since its launch 70 years ago, the National Health Service has transformed the health of the nation and established itself as one of this country’s greatest assets. Our NHS is always there when we need it and those who live in this country contribute to the long-term sustainability of the service over their lifetime. The NHS is the envy of the world and will always be free at the point of delivery.

 

The immigration health charge represents the most cost-effective and fair means of ensuring that temporary migrants make a financial contribution to the operation of the service. Doubling the charge will still ensure that official health costs associated with migrating to the UK remain lower than or comparable with those of other nations, including those in Europe, North America and Australasia. The charge is paid by non-European Economic Area temporary migrants who apply for a visa for more than six months or apply to extend their stay in the UK for a further limited period. It is paid up front as part of the immigration application process and is separate to the visa fee.

 

From the point of arrival in the UK, a charge payer can enjoy the same access to the NHS as a permanent resident. They can use the full range of NHS services without incurring treatment charges and without having made any tax or national insurance contributions in the UK. They generally pay only those NHS charges that a UK resident would also pay.

My Lords, the Minister keeps talking about “the UK”, but there are four health services within the United Kingdom. Can she tell the House whether this order covers all those health services, or just England?

I am talking about the United Kingdom, so I am talking about the devolved Administrations as well—I think. Yes, I am. I thought it was a trick question and so doubted my own mind. Going back to what temporary, non-EEA migrants might have to pay for, they generally pay only those NHS charges that a UK resident would also pay: an example might be prescription charges in England. They will also be charged for assisted conception services in England, should they choose to use them.

 

The charge rate has not increased since its introduction in 2015. It is currently £200 per year; students and youth mobility scheme applicants enjoy a discounted rate of £150 per year. To date, the charge has raised over £600 million for the NHS. Income is shared between England, Scotland, Wales and Northern Ireland using the Barnett formula. That answers the noble Lord’s question.

 

The draft order amends Schedule 1 to the Immigration (Health Charge) Order 2015, to double the annual amount of the charge across all routes. Students, dependants of students and youth mobility scheme applicants would continue to pay a discounted rate, which would rise to £300 per person. The annual amount for all other relevant application categories would rise to £400 per person.

 

The Department of Health and Social Care has reviewed the cost to the NHS of treating charge payers in England. It estimates that the NHS spends, on average, £470 per person per year for all migrants who pay the charge. This calculation includes those surcharge payers who actually use the NHS and those who do not. Where the cost has been calculated on the basis of those who use the NHS, the figure rises to £1,300 per person per year. This means that temporary migrants are currently paying the surcharge at a significantly lower rate than the amount it costs to treat them each year.

 

The proposed new charge level is intended to better reflect the costs to the NHS of treating those who pay it. However, it is important to note that it will remain below average cost recovery level, in recognition of the wider contributions that migrants make to this country. It will also continue to represent good value compared to health insurance requirements in other comparable countries.

 

The charge should not be conflated with the system of hospital treatment charges for overseas visitors provided in NHS legislation. That provides a separate framework for recovering treatment costs from short-term visitors and those without lawful status. The NHS charging system observes the important principle that immediately necessary or urgent medical treatment is never withheld, irrespective of the patient’s status.

 

The Government believe it is fair that temporary migrants make a financial contribution to the comprehensive and high-quality range of NHS services available to them during their stay. The charge will remain a good deal for migrants. Even at the increased rates, they will still pay less than it costs the NHS to treat them. By increasing the charge, the Government estimate that a further £220 million a year could be generated, helping to protect and sustain our world-class healthcare system for everyone who uses it. By way of illustration, England’s share of the additional income could fund around 2,000 doctors or 4,000 nurses. I commend this order to the House.

 

Amendment to the Motion

At end to insert “but that this House regrets that the Order provides for an unaffordable level of fee, particularly for those who came to the United Kingdom as young children; does not take into account the contribution of migrants who are taxpayers; and may have a detrimental effect on recruitment for key public services, including nursing.”

My Lords, as the Minister said, for the last three years, under the Immigration Act 2014 an annual health charge has been payable by non-EEA nationals making an immigration application to enter or remain in the United Kingdom. That charge has been on top of any immigration application or visa fees, and was introduced as part of a clampdown on what has been described as health tourism.

 

I do not intend to go down the same road as the Secondary Legislation Scrutiny Committee, whose report on this order states, at paragraph 7:

 

“While acknowledging that the revenue to the NHS will be increased, it is still not clear to the Committee why the charge remains below the full cost of supplying these services”.

 

 

It ended by suggesting that:

 

“The House may wish to ask the Home Office Minister to justify this subsidy”.

 

 

That is not an invitation that I will take up; it is for the Minister whether she chooses to explain the Home Office’s argument to justify this “subsidy”, as the committee described it. I want to raise the matter of the high level of the charge, the increase and the impact that it will have.

 

As the Minister said, the order doubles to £400 a year the immigration health charge payable when an immigration application is made, with it being doubled from the current £150 to £300 for students and their dependants. The payment cannot even be made in instalments, and must cover the total cost up front for the duration of the leave applied for. It is payable in respect of each individual named on the immigration application.

 

The present charge was determined in 2015. What has the increase in NHS expenditure been since then on average for immigration health surcharge payers? Could the Government give a breakdown of their estimate of £470 on average per year per charge payer? The Secondary Legislation Scrutiny Committee drew attention in its report to the fact that one part of the Government’s documentation referred to the revised charge being £470 per year per person, while a subsequent part of the impact assessment refers to it being £480, but perhaps that is not worth quibbling about.

 

What was the equivalent estimated cost in 2015, when the charge was first imposed? The Secondary Legislation Scrutiny Committee tells us at paragraph 3:

 

“When the charge was originally introduced in 2015 we drew the matter to the attention of the House, questioning why it was set at £200 per person per year, significantly below full cost recovery levels, then estimated at £800 per person per year”.

 

 

If I am looking at comparative figures—if not, I am sure that the Minister will correct me—how was the full cost recovery deemed to be £800 per person per year in 2015 but is not at that level currently? Apparently it is now either £470 or £480. That fact does not exactly inspire much confidence in the figures put in front of us in the Government’s documentation. Can she comment on that?

 

The charge that we are talking about is payable on an annual basis until such time as the person to whom the payment relates is granted indefinite leave to remain in the UK or returns to their own country at the end of their visa period. Applying for two and a half years of limited leave to remain will require an immigration health charge of £1,000 to be paid. As I understand it, paying the charge means that the person covered is exempt from the system for undocumented migrants in the UK of up-front charging of some 150% of the estimated cost of treatment prior to accessing secondary NHS healthcare.

 

The increased charge will hit children who have grown up in the UK but have uncertain status particularly hard. These are not temporary migrants. If they can make an application for leave to remain they are granted just two and half years leave at a time and will have to make four applications over the course of 10 years. That costs just over £6,500 in application fees, plus an additional £2,000 for the immigration health charge, at the current rate of £200 per annum, before they can be granted settled status or indefinite leave to remain—a total of just over £8,500. With the doubling of the immigration health charge to £400, which the Government intend to levy from February next year, a further £2,000 will be payable over the 10-year period, bringing the total to over £10,500.

 

For migrants on lower incomes in particular, this significant further increase will mean even greater difficulty in finding the not inconsiderable up-front costs required to secure or maintain regular status in the UK. That will have an impact on the quality of children’s lives, not least if problems arise over finding the money to pay the rent, and increase the prospect of poverty or deepening existing levels of poverty. Bear in mind that an immigration application can become invalid by the non-payment or even partial payment of the immigration health surcharge. Yet, without regularised status a migrant cannot access housing, education and health services, the latter in particular posing a potential public health risk.

 

I accept that it is true that there is a system of exemptions and fee waivers, but apparently less than 8% of children are granted fee waivers. A family of four with working parents would be required to save some £8,100 every two and half years, excluding legal costs. As I understand it, that is more each year in immigration fees than the average UK household spends on food. Yet, parents in employment would also pay national insurance and taxes, contributing towards the cost of the NHS. They would thus, in effect, be charged twice.

 

Interestingly enough, as far as I can see, the impact assessment makes no reference to the potential impact on children and young people and their rights—in particular for those who have grown up in the UK and are on the 10-year route to settlement—of the doubling of the immigration health surcharge. How does that square with the Government’s stated commitment to consider children’s rights when developing policy? Will they now carry out that assessment? What steps will the Government take to ensure that low-income families who might be ineligible for a fee waiver under the current system do not risk losing their status because of the high fees and the high health surcharge, along with the requirement for up-front payments?

 

If I am right in believing that a report by the Independent Chief Inspector of Borders and Immigration is due on Home Office charging for services, including the impact of high fees in the immigration system, why is the immigration health surcharge being doubled now before we have had the chief inspector’s report?

 

The immigration health charge will also have an impact on those non-EEA citizens either working or thinking of coming to work in this country. The increase in the immigration surcharge could also worsen the skills shortage in a number of key areas, such as the construction and hospitality sectors, and in health services. For example, the charge has to be paid by non-EEA international nurses and their families coming to work in health and care services across the UK. At present, there are apparently some 40,000 such nursing vacancies in England, a figure that is estimated to rise further. There appear to be no guarantees that the immigration health charge will not be applied to EU citizens after Brexit and potentially make skills shortages even more acute.

My Lords, I thank the Minister for explaining this order and I wholeheartedly agree with the noble Lord, Lord Rosser, that this House should not approve it, for the three reasons he set out. The first is that, taken together with other excessive charges made by the Home Office on those seeking to come to or remain in the UK, the increase in the immigration health charge provided by this order makes it unaffordable for many to come to or remain in the UK, even though they have a legal right to do so. Secondly, while the immigration health charge is intended for those seeking to stay temporarily in the UK, as the noble Lord, Lord Rosser, has said, many people whose applications for permanent leave to remain are being considered will also be unfairly caught by this charge. The final issue is that, in addition to paying the immigration health charge, many of those affected will be working in the UK, paying income tax and national insurance. They will effectively be paying twice for any treatment they receive from the National Health Service.

 

We have discussed before the level of charges levied by the Home Office for such things as visa applications. These are way above the cost of processing such applications. When this 100% increase in the immigration health charge is added to these already excessive costs, it becomes unaffordable for many even to contemplate coming to the UK, even though they are perfectly entitled to do so. As the noble Lord, Lord Rosser, pointed out, children seeking permanent leave to remain are now granted only a maximum of two and a half years’ leave at a time. They would have to make four applications before they reach the required 10 years’ residency, costing £6,521 per child at current prices. They are now going to have to add another £4,000 in immigration health charges, bringing the total for one child to £10,521 just to remain in the UK.

 

There are exemptions from the health charge and other immigration charges, yet the process is so complicated and ineffective that, as the noble Lord said, only 8% of children are granted fee waivers. Many families are having to make the choice between being plunged into poverty and being forced to leave the UK—which is, of course, exactly what this Government are trying to do, whether or not they have changed the packaging from “hostile environment” to “compliant environment”.

 

The Government’s own impact assessment clearly anticipates a reduction in the number of people seeking to enter or remain in the UK, as a result of doubling this charge. The impact assessment also shows that there will be a net cost to the Exchequer in dissuading working migrants from coming to the UK, because immigrants contribute more overall to the public purse than they cost in public expenditure. They do so already, without the immigration health charge increase. There is one clear conclusion from the impact assessment. This is a financially self-harming, ideological and constituent part of the hostile—or compliant—environment, designed to deter those from overseas coming to or remaining in the UK, even if they come here to make a valuable contribution to the UK economy.

 

The irony of the Government’s whole approach to immigration and the punitive charges levied by the Home Office is encapsulated by the case of nurses from non-EEA countries coming to work in the NHS. First, this Government create a hostile environment for all immigrants by holding a referendum on membership of the European Union where false stories of excessive immigration are deployed by the leave side, resulting in a massive increase in hate crime against those from other countries while making EU migrants in particular feel vulnerable and unwanted. Having caused an exodus from the health service of EU nationals working in it, the NHS is then forced to employ non-EEA nationals to fill the gaps. It has to pay an additional £1,000 per non-EEA national employed per year in immigration skills charges. Meanwhile a qualified nurse from, say, the Philippines—a country that can ill afford to spend money training nurses only to see them leave for the UK once qualified—not only costs the NHS £1,000 a year more than an EEA national employed in the same role but also has to pay £400 a year towards the cost of the NHS, even though she is employed by the NHS. She will effectively pay twice for the NHS by paying tax and national insurance in addition to the immigration health charge.

 

Of course, revenue from the immigration skills charge is supposed to be put into training UK citizens to reduce the need for skilled immigration. Instead, the Government have abolished student bursaries for nurses, making it less likely that UK citizens will train to become qualified nurses and creating more demand for nurses from overseas. Numbers applying to begin training in September 2018 dropped 12% when compared to the same time last year, resulting in a total decline of 16,580 applications since March 2016—the last year in which students received financial support through the bursary. The fall in mature student numbers has been even more extreme, with a 16% drop by the June application deadline compared to the same point last year and a total decline of 40% since June 2016. As the noble Lord, Lord Rosser, said, there are currently estimated to be 40,000 nurse vacancies in England alone.

 

This Government are creating not only a hostile environment for immigrants but a hostile environment for common sense and decency. This order is very much to be regretted.

My Lords, the Refugee and Migrant Children’s Consortium is deeply concerned about this order, which doubles the health surcharge. These concerns are, I suggest, important because of the interaction with other charges. In the past, people who were here legally but with uncertain future residency could expect to remain after six years, with good behaviour. Now they will be granted only two and a half years in extensions and thus may have to pay over £6,500 just to remain, as the noble Lord, Lord Rosser, pointed out. On top of this, they may have to find £2,000 for an immigration health surcharge, in what one might call a double whammy. This is particularly hard on those on low earnings because of their uncertain status. They are also doubly taxed if they suffer PAYE and national insurance on their wages.

 

The noble Lord, Lord Paddick, rightly mentioned the case of nurses from the Philippines. Ill health, or health at all, may thus become a cause of homelessness if rent arrears lead to eviction. The Government may say that there are exemptions for some. However, children in care are exempt, but not children who live with their natural family. A family with four children may have to pay £8,100 on several occasions. The situation may be even worse if the family is also paying fees to register for British citizenship. An impact assessment has been published, but it makes no reference to working parents and their children.

 

This is an anti-family measure. Her Majesty’s Government should withdraw this order and think again. They must consider its impact on those least able to pay and not just on fat cats and non-doms. Will they please also rethink the exemptions? I support the amendment.

My Lords, I rise to speak in support of the amendment moved by my noble friend Lord Rosser, particularly its reference to those who came to the UK as young children. I apologise if I repeat some of the arguments already made, but they bear repetition. I am grateful to the Refugee and Migrant Children’s Consortium for drawing to our attention the implications of doubling the surcharge for children and young people making immigration applications from within the UK on the basis of prior long residence in the UK, many of whom are vulnerable and living with parents who cannot possibly afford this surcharge.

 

I am struck by how the Government constantly refer to it as a charge for “temporary migrants”. The evidence base attached to the statutory instruments says that. The Minister’s Written Answer of 14 November to the noble Lord, Lord Jones of Cheltenham, said it. The Minister for Immigration said it when introducing the statutory instruments in committee in the other place, and this afternoon the Minister constantly used the term “temporary migrants”. As my noble friend said, these children are not temporary migrants. Many have grown up here, look to make a future here and have a legal right to do so. Why are they and their parents being expected to pay a surcharge which is designed for temporary migrants? I would be grateful if the Minister could answer that.

 

As we have heard, when added to the fees that families are already required to pay for their children to acquire indefinite leave to remain, the total bill over a 10-year period will come to more than £10,000.

 

Last week, the Parliamentary Under-Secretary of State for Children and Families made a Written Statement to mark the anniversary of the UN’s adoption of the Convention on the Rights of the Child. He stated:

 

“The UK is a proud and long-standing signatory of the United Nations convention on the rights of the child … and this Government remain fully committed to the promotion and safeguarding of children’s rights.

 

 

The UNCRC sets out an enduring vision for all children to grow up in a loving, safe and happy environment where they can develop their full potential, regardless of their background. This Government share that vision and are dedicated to providing the best possible opportunities for all children but especially those who have the hardest start in life”.—[Official Report, Commons, 20/11/18; col. 21WS.]

 

 

Will the Minister explain to your Lordships’ House how doubling the surcharge on top of the exorbitant fees these children and their families already face squares with that very positive vision?

 

According to the consortium, the cumulative cost of the fees and surcharge is,

 

“seriously impacting on the quality of children’s lives, affecting their development and forcing families into long-term poverty”.

 

Do the Government know or even care, given that they have not even bothered to make any reference to the potential impact of the surcharge increase on children and young people and their rights in the impact assessment provided? Will the Minister undertake to rectify this omission and at the very least ensure that a child’s rights impact assessment is provided retrospectively and, perhaps more importantly, in all future regulations relating to both immigration and citizenship fees and charges affecting children? This is not the first time that we have had regulations of this kind without any assessment of the impact on children.

My Lords, may I recount a story to the House from several years ago? I think it was around the time I was first appointed Secretary of State for Health. I was visiting a GP surgery in Cambridge, close to my constituency. The GP said to me, “There’s one thing I want you to think about. We have, obviously, many students come to Cambridge University. When they arrive they register with GPs, and many register with us. Happily, in some cases they never come to see us, but others do. When they come to see a doctor, I talk to them and prescribe whatever it might be. Then, when they go out of the door, the Americans, the Australians and the Chinese—many of these students come from outside the European Union—immediately go to the reception desk and ask where they’re going to pay. They are rather staggered to be told, ‘But you’re not paying. You pay nothing’. They say, ‘How can this be? Here we are in your country. If we were at home, we would be paying’”. They regard it as an absurd proposition. They are not here permanently and, in their view, they are therefore not entitled to the free care that those permanently resident in the UK should receive. This is an anomaly created by the use of the term “ordinarily resident” for access to NHS services. Although, as Secretary of State, I did not introduce the health surcharge, I none the less supported it when it was introduced.

 

The noble Lord, Lord Rosser, made a good job of objecting to something which I think he knows—and the House should know—is an entirely reasonable proposition. Not only should people who come here to take advantage of the opportunity to work here make the appropriate contribution to NHS services, the amount should be determined in relation to the average costs, which is a bargain for anyone actually accessing NHS services. Therefore, I will not support the amendment and support the order.

 

I say this in parenthesis to the noble Lord, Lord Paddick, about Filipino nurses. The Philippines has consistently—over many years—trained more nurses than it could possibly require in the expectation that Filipino nurses will get jobs abroad, principally in America. Many Filipino nurses came to Papworth Hospital in previous years. They have been extremely successful and many have settled. In recent years, we have had principally European Union nurses, but we would do well to have more Filipino nurses in future—if we can attract them, given the higher salaries that they enjoy in America. We are certainly not depriving the Philippines of nurses that it requires and it has never been the Government’s intention to do so.

 

That said, I shall not support the amendment. The Government are right and moderate in the increase to the charge that they seek.

My Lords, in the absence of the noble Lord, Lord Grocott, I feel brave enough to rise to my feet. I declare my interest as a governor of Coram, the children’s charity. I shall agree with the noble Lords, Lord Lansley and Lord Rosser, as a true Cross-Bencher should. I understand, and in principle do not disapprove of, charging those from outside the EEA for using the wonderful NHS. If it produces £220 million for the NHS, I think we would all say hurrah. For many migrants, it is undoubtedly a very good deal and a lot cheaper than insurance.

 

But—as the Minister knows, there is always at least one “but”—I should like to make a few points. They concern what I hope are unintended, not deliberate, consequences of the IHS. The noble Lord, Lord Teverson, asked a Written Question on 12 July about whether there would be a children’s rights impact assessment of the increase in the fee. In her reply on 23 July, the Minister said:

 

“A full impact assessment will be published alongside the draft Order”.

 

 

In the event, the impact assessment had been completed three weeks earlier on 3 July, but having read it extremely carefully to see whether I could find any trail within it which looked like a children’s right assessment, all I could find, at the top of page 17, in subsection F.5, was a comment about the proportion of in-country family visa applications which may be eligible for the waiver. It said that Her Majesty’s Government,

 

“is also considering options to mitigate the consequence an increase in Surcharge may have for applicants’ affordability”.

 

Given that the impact assessment says that the Government are considering options, what are those options and how far have Her Majesty’s Government gone in their thinking about them? Does the Minister genuinely think that the impact assessment before us includes anything like a full children’s impact assessment?

 

Secondly, when we are talking about the fee waiver system, which is extremely well intended, many of us outside the Home Office struggle to understand how it is working at all. The reason is that the Home Office has the relevant statistics and we do not. In May last year, Coram, of which I am a governor, sent a freedom of information request to the Home Office, to which the Home Office replied. The statutory response timeframe is 20 days. In this case, it excelled itself by responding nine months later. It said that roughly 7% of fee waiver applications were successful. Why was a new request for the 2017 statistics in a freedom of information request denied by the Home Office on the grounds that it would be too costly to compile it? Given what we heard earlier—that the Government, in their wisdom and munificence, are deliberately undercharging when it comes to the IHS—how can the Home Office justify not acceding to the freedom of information request?

 

We simply cannot judge whether the waiver scheme is working properly if we do not have the data. I am not trying to be awkward or embarrass the Minister or the Government; we simply need to know the figures so that we can come to a reasoned judgment, together with the Home Office, on whether the fee waiver system is working in the way we all know it was intended to work. It would be helpful to all sides if we were able to do that.

 

Thirdly and lastly, we welcome the report of the Independent Chief Inspector of Borders and Immigration. I hope he will include the effect of the IHS when he publishes his report, and we look forward to its findings. If it does not contain an analysis of the effect of the IHS, will the Minister say why not? The children we are talking about find it very difficult to have their voices heard. Frankly, we are inadequate substitutes for these children, though we do our best to communicate their raw and often very painful testimony. But they have an inalienable right to be heard, and it is in that spirit that I ask these questions—their questions—and I look forward to the Minister’s answer.

My Lords, it has been an interesting debate for me because other noble Lords have argued from points of view that I have not considered. I support the amendment to the Motion in the name of the noble Lord, Lord Rosser, simply on the basis of unfairness and injustice.

 

I want to take issue with some of the things said by the noble Lord, Lord Lansley. It seems to me that we do not take into account the value of immigrants in Britain, and again and again that creates a hostile environment. I shall quote a government press release:

 

“We welcome long-term migrants using the NHS, but the NHS is a national, not international health service and we believe it is right that they make a fair contribution to its long-term sustainability”.

 

 

That is true, but the NHS is paid for by everyone who pays tax in Britain. This includes immigrants, who overwhelmingly pay more in tax than they receive—and perhaps make the wider contributions that the Minister was thinking about when she mentioned that. They already make more than their fair contribution to the running costs of the NHS, but the Government do not seem to appreciate that, and I ask why. All the figures suggest that immigrants give more than they take, so why are the Government not recognising that?

 

This dog whistle rhetoric of calling it,

 

“a national, not international health service”,

 

is a particularly harsh insult to the 144,000 NHS staff whose nationality is non-British. The truth is that we do have an international health service, which runs on the hard-working dedication of so many people who move here from all over the world to look after the people who live here in the UK. It is hard at the moment to see why anybody would want to come here in view of the sorry, xenophobic state we are in, but they still do.

 

Not only is our immigrant workforce being blamed, yet again, for the failures of government policy, but now they are being charged £400 a year for the privilege. The same people who came here to work so hard to deliver our National Health Service are now being told that they do not deserve to have their own health needs looked after properly. If this kind of policy had been introduced in 2010, people would have been rightly disgusted. It is the kind of thing that only UKIP would have got away eight years ago, and everyone would have thought it wrong. But somehow, in our society today, we have become so hostile, so fast, that now such policies just seem normal.

 

This change is a continuation of the Government’s obsession with blaming all the country’s problems on immigration. As a Green, I strongly resist any measure of hostility based on where in the world a person was born. In particular, I ask the Government to consider whether it is particularly unfair to charge an NHS surcharge to people who work in the NHS. I am dubious about the amount that the Government claim they will raise. I would like the Minister to confirm that amount, because it would be interesting to see later whether it is realised.

 

Finally, do the Government agree that the best way to fund the NHS is to invest in it properly? Only the Government can do that.

My Lords, I thank all noble Lords who have taken part in this debate.

 

First, in virtually every country in the world, all migrants who move to a new country expect to pay towards their healthcare. In most countries this is usually in the form of medical insurance or through up-front payments when accessing healthcare. Many countries require health insurance as a condition of a migrant’s visa. For example, all foreign fee-paying students applying to study in Australia or New Zealand are required to hold acceptable medical insurance as a condition of their visa.

 

Healthcare can be needed at any time, regardless of age or profession. Anyone who has purchased healthcare insurance will know that it will likely cost more for those most at risk, such as the elderly, the very young or those with long-term health conditions. As noble Lords will know, that is not the system we operate in the UK. Our NHS does not charge more to those who need it most. However, everyone must make a contribution towards the costs of the NHS, to ensure that we all have access to care when we need it. It is therefore right that migrants who have access to the NHS in the same way a British citizen would if they needed it, pay a fair share towards it.

The point is, as the noble Baroness, Lady Jones, said so well, that all those other jurisdictions the Minister has mentioned do not pay for their health services totally through national income taxation, which is paid by migrants in this country. That is the fundamental difference and is the whole point of the argument.

I will give an example: if I went to America and worked there, I would pay taxation but would also pay health insurance. It is no different.

It is completely different.

I think we will have a disagreement on a point of principle, but if the noble Lord could let me outline the Government’s position—I will certainly take interventions at the end—I will explain why temporary migrants coming to this country get a fair deal.

 

A number of noble Lords have raised the issue of NHS professionals and how they ought to be exempt from the charge. The Government fully recognise the contribution that international healthcare professionals make to the UK, but it is only right that they also make a proportionate contribution to the long-term sustainability of the NHS. In that regard, NHS professionals are in the same position as other providers of essential public services, including teachers.

 

I recognise that there are concerns about the financial impact on nurses. However, the answer is not to exempt nurses from the charge but to increase their pay. This is happening. All NHS nurses will benefit from a pay increase as set out in the Agenda for Change framework. It is important to remember that the charge offers access to healthcare services that are more comprehensive and at a lower cost than those in many other countries. Most professionals who choose to work overseas need to have the appropriate medical insurance in place, which is the point that I made to the noble Lord.

 

Paying the charge ensures that the income generated goes directly to NHS services, helping to protect and sustain our world-class healthcare system for everyone who uses it. I am conscious of the concerns regarding the combined cost of the charge and visa fees. However, the charge is set at a competitive level and will remain low compared to the potential benefit, which is free access to the NHS. It offers better value than private medical insurance where the premiums are more expensive. As a matter of interest, I looked at the average insurance cost for the average American, which is $320 per month—significantly more than we would expect to pay. The Government are clear that migrants must pay the charge when they make an immigration application and should plan their finances accordingly. The costs of both the health charge and the application fees are available online and should not come as a surprise.

 

Many noble Lords spoke about vulnerable groups. We are committed to ensuring that vulnerable groups can access the NHS without charge. There are several groups applying for leave to remain in the UK who are exempt from the requirement to pay the immigration health charge as set out in the Immigration (Health Charge) Order 2015, and they continue to apply. They include people who apply for leave to remain relating to an asylum or humanitarian protection claim, and would absolutely include people who the noble Lord, Lord Hylton, spoke about, such as refugees, victims of modern slavery and children in local authority care.

 

Those who are exempt from paying the immigration health surcharge or who have the requirement waived are treated the same as those who have paid it, so they are entitled to virtually all NHS care free of charge. Noble Lords, including particularly the noble Baroness, Lady Lister, and the noble Lord, Lord Rosser, talked about how the requirement to pay up front could discriminate against those on low incomes. As I have said, the charge is set at a competitive level and is low compared with the potential benefit of free access to the NHS. Migrants are aware of the rules when applying for a visa, including the need to maintain and accommodate themselves in the UK, pay the health charge—and ensure they plan their finances accordingly. As I have said, and as noble Lords have mentioned, there are exemptions available.

 

A number of noble Lords talked about children. I am aware of the concerns raised about the impact of increasing the charge on children. Children are as likely as adults to use NHS services; as such, it is only fair that their parents or guardians contribute to the cost of their care. The Government continue to ensure that those who are most vulnerable are protected. Where an application fee is waived on destitution grounds the surcharge is also waived and, as I have mentioned, exemptions are in place for children in local authority care.

 

The noble Lords, Lord Paddick and Lord Rosser, talked about nurses.

The Minister is moving on to another issue, but could we stick with children for a moment? A number of noble Lords made the point that these children are not temporary migrants. At the outset, following an intervention, she said she would explain how temporary migrants get a fair deal. Then she said that migrants are aware of the rules when applying for a visa—but we are talking about children who are here, who have been here for some time, and who want to stay here. Could she please address that point?

If you intend to be here temporarily, you apply for a temporary visa and you are captured by the immigration health surcharge, but clearly if you have indefinite leave to remain or are a citizen of this country, the health surcharge no longer applies to you.

But the point is that, to get leave to remain, people have to pay over 10 years and, as noble Lords have said, that amounts to over £10,000 when you add in this new surcharge. Therefore, it is making matters very difficult. It is a Catch-22 situation, is it not? How do the children get to show that they need to remain if they cannot afford it and the ability to afford it is being reduced by the health surcharge attached to the fee?

My Lords, in estimating the charge, we estimated the cost of providing healthcare to someone who is here temporarily. The cost was estimated at £470 per person. To answer the point raised by the noble Lord, Lord Rosser, we decided to set the charge at £400 and not at full cost recovery because we recognise the contribution that migrants make to this country. We have not set the charge above cost recovery, as the committee had suggested.

 

I realise that the surcharge might make an application very expensive but we think that it is proportionate, given the access to healthcare that people will avail themselves of, and of course it is considerably cheaper than if they were to have private healthcare insurance. I am not decrying the fact that it might be expensive for a family—I appreciate that—but it is significantly cheaper than if they were to have private healthcare insurance, and of course the people concerned generally come here to work. I do not decry the fact that it is expensive; I am saying that, first, it is significantly cheaper than what we might pay for private healthcare as migrants going to any other country and, secondly, the service that they will get from the NHS once they have paid the surcharge has to be taken into account.

I am sorry to push it, and I promise not to do so again, but a number of noble Lords have pointed out that there is no child rights impact assessment, even though I think that one was promised in response to a Written Question. Can the noble Baroness undertake to take back to the Home Office the concern raised here so that in future, whenever regulations affecting children are brought before us, the impact assessment will include a proper assessment of the impact on child rights and not the cursory words to which the noble Lord, Lord Russell, referred?

I can certainly undertake to take this away and provide for the noble Baroness and other noble Lords a more fulsome illustration of the impact. I have an illustrative example of a nurse and I can write to noble Lords with that.

Before the noble Baroness returns to her response, I want to say that it is not appropriate to compare this country with places such as America, because we have a national health service and they do not. The point about our National Health Service is that it helps us to have a healthy and perhaps happier population, and that is good for everybody: it is good for the Government and for every single person who lives here. Therefore, it is not a gesture of good will from the Government to create a good National Health Service; it is imperative to our democracy.

My Lords, I gave the example of America precisely because we have a national health service. Were I to migrate to America for a job, I would have to have healthcare insurance at a huge cost. The noble Baroness is right. There is a huge disparity in healthcare outcomes in America between those who can afford health insurance and those who cannot, and I am glad that we have an NHS for that very reason.

My point was that we are not taking into account the wider implications of immigrants paying into our tax system, but then charging them on top of that. To me, that just does not seem fair.

As I said earlier, if I went to America and paid my taxes, I would still need health insurance on top of that. The point I am trying to make about the surcharge is that, compared to what one might pay for private healthcare insurance in most countries, this is a very reasonable charge to access what I think is one of the best healthcare systems in the world.

You are not going to convince us.

No.

I do not want to prolong the agony for the Minister, but the point about America is that the tax people pay there does not pay for healthcare. That is why people have to have insurance. Immigrants come to this country, get jobs and pay national insurance and income tax, which pays for healthcare. But only immigrants have to pay a charge in addition to the national insurance and income tax they pay to fund the health service. Can the Minister explain why?

Temporary immigrants have to pay the healthcare charge, but anyone with indefinite leave to remain or who is a citizen of this country contributes to the NHS through general taxation. We are not going to agree on this.

I cannot bear that assertion being put on the record without being refuted: American taxation pays for healthcare—it pays for Medicare, Medicaid and the CDC. American public expenditure on health is nearly as large, as a proportion of GDP, as British expenditure on health. It is just incredibly inefficient. As my noble friend says, those who travel to America and work do not get access to Medicare or Medicaid.

I am glad to have a former Health Secretary standing behind me to put noble Lords—and me—absolutely right.

Will the Minister come back to the point I raised about the inadequacy of the information we have about how effective the fee-waiver system is?

I will. I will not give him an adequate response, but I will tell him why; if that is okay.

 

The noble Lord, Lord Rosser, asked why the charge was set below cost recovery levels. I think I have answered that. He asked why the estimate in 2015 of £800 per person is so different from what we have now. It is because in 2015 it was just that, an estimate. We can now give an actual figure, given that people actually use the health service. The noble Lord also asked why we decided to double it on the basis of Department of Health and Social Care analysis. He will know that we made a commitment before the 2017 general election to triple the surcharge. We have not; we have doubled it. It was because we had made a manifesto commitment that we did not consult on the issue.

 

The noble Lord also asked about EU citizens. We are in the process of negotiating reciprocal healthcare arrangements with the EU. We have reached agreement on citizens’ rights that will protect EU citizens and their family members who are resident in the UK by the end of the planned implementation period on 31 December 2020. We have made it clear that the immigration health surcharge will not apply where EU citizens make immigration applications during the implementation period after the UK leaves the EU. We will set out our plans for the future border and immigration system in a White Paper later this year, which, noble Lords will work out, has not long left. Another noble Lord asked that question. I will not pre-empt or trail the White Paper with further detail at this stage.

 

We have been through the double taxation argument. I do not think that the noble Lords who asked about it agree with me, but I have made the point that the charge is fair not only to migrants but to UK national and permanent residents who have or will make a greater contribution to the NHS over their working life.

 

The noble Lord, Lord Paddick, and the noble Baroness, Lady Jones, talked about the compliant environment. This is nothing to do with the compliant environment. The charge is intended to ensure that temporary legal migrants make a fair contribution to the cost of their healthcare in the UK. In contrast, the compliant environment is a suite of compliance, deterrence and data-sharing measures that form part of our overall approach to deterring and tackling illegal migration and protecting public services.

 

The noble Baroness, Lady Lister, asked why children do not feature in the impact assessment. This is because it is at a macro level rather than an individual level. I know she does not like that answer but individuals are fully catered for in the system of fee waivers and exemptions, and a child is as likely to need healthcare as an adult.

I know I said I would not come back to this issue but no impact assessment deals with individuals; they deal with groups. An equality impact assessment would deal with equality groups. A child’s rights impact assessment is supposed to inform us, not whether they are more or less likely to have healthcare, but what the impact is going to be on the rights of that child. All I was asking for was an assurance that future regulations have a proper child rights impact assessment as a part of them.

I take the noble Baroness’s point because in everything we do with law, we have to consider the rights of the child. That is a basic requirement on the Government. It may be implied, it may not be, but I entirely take the noble Baroness’s point.

 

The noble Lord, Lord Rosser, asked me about undocumented children having to make four applications over 10 years at over £10,000. These applicants fall within the scope of specified human rights applications for which fee waivers are available—we have gone over that point—but, of course, parents may apply for the fee waiver for the child.

 

We have produced the policy on equalities assessment and will provide it to Peers who have spoken in this debate and place a copy in the House Library. I cannot stand at the Dispatch Box and say that it includes children. I suspect from what the noble Baroness says that it does not, so I go back to my previous point.

 

The noble Baroness asked about the chief inspector’s report and when it will be published. The immigration fees and the surcharge are obviously two separate things. The Government made a manifesto commitment to increase the surcharge and it is important that we deliver on that.

 

The noble Baroness also asked about the proportion of applicants receiving a waiver—this goes to the point made by the noble Lord, Lord Russell of Liverpool—but we have not published that information. However, we are reviewing the process because, as time goes on, these issues necessarily become more complex. I know that does not answer entirely the point made by the noble Lord, Lord Russell, and the noble Baroness, Lady Lister, but we will be reviewing that.

On the point I made that in the impact assessment there is a reference to the Government considering options for families who are experiencing hardship, what options are the Government considering and where are they in their thinking?

I cannot give the noble Lord any more information on that at this point but I am sure it will be released in due course. He also asked about the Coram freedom of information request. The first response was based on management information from a live database which is subject to variations as the year progresses. The second was not answered because of a policy to release only published information. Government departments often do not release information if it is not published information, although I have given management information with caveats before. The Government are seeking to resolve this issue.

Does the Minister accept that it is extraordinarily difficult for us to try to work out the effects and the effectiveness of the fee-waiver system in the absence of any reliable or up-to-date data? How can the Government make decisions about it if they do not have the data? If they do have the data, please can they share it with us?

We do not share management information data because it is purely that—management information. As I understand it, we are seeking to resolve this issue with Coram Children’s Legal Centre, and when we do I will be happy to write to the noble Lord with the outcome.

 

I hope that noble Lords are satisfied with my response, although I suspect they are not, and that the noble Lord will feel happy to withdraw his amendment.

I thank the Minister for her response. I did not get the impression that she was particularly excited about some of the things that are presumably in the brief in front of her when she responded to the numerous questions that have been asked. Nevertheless, she always—and I mean this—seeks to respond to the questions raised. We are grateful for that—and I mean that too.

 

I also thank all noble Lords who have participated in this debate. It seems quite a long time ago that I moved the amendment. I do not intend to make another lengthy speech or go through all the points. I was certainly struck by the view of the noble Lord, Lord Lansley, that it is a bargain. Whether he believes that it is a bargain for young children, which is one of the issues mentioned in my amendment, I do not know. Obviously, from the way he said it, I assume that he does, but I and some other noble Lords fundamentally disagree with his view. On that score, though, I respect his opinion and the arguments that he made.

 

During this discussion and in the response we have had from the Minister on behalf of the Government, great stress was laid on estimated costs and how the charge has been looked at against estimated costs. Very little was said about looking at the income of some of the people who will have to pay those costs. It is all being looked at from a cost point of view; it has quite obviously not been looked at from the point of view of the impact on the total incomes of those who will have to pay the charge, not least of those in low-income families.

I apologise for intervening on the noble Lord. I said that I would write to noble Lords with an illustrative example of a nurse, if that helps.

I appreciate that the Minister said that she would write. I would be very grateful indeed if, when she writes, she will address this issue of the impact of the charges on the incomes of those who will have to pay it, particularly those on low incomes and with families with children.

 

There is another example of the way that the Government look at the issue. When reference was made to the impact on nurses, the answer was: “You solve it by increasing pay”. Yes, there has been a small increase in nurses’ pay, but there have not been very big increases over the past eight years. The charge is being doubled but I do not think that nurses’ pay is being doubled. I do not think that nurses will necessarily feel that the relatively small increase they have just had—they have not had much over the past few years—will be any real compensation for having to pay, for one specific item, a doubled charge. One does not get the impression that the Government have looked at this from the point of view of the impact on incomes, particularly for those among the less well off.

 

I think I heard a comment—I will withdraw my remarks if I am incorrect—which almost seemed to say that when low-income families are faced with this additional charge, it is up to them to arrange their finances accordingly. That was the thrust of the argument and how it came across to me. That is another indication that this has not been looked at from the point of view of the impact, particularly on people on low incomes and with children.

 

I am grateful to the Minister for saying that she will write. I hope she will perhaps reflect further on the point made by the noble Lord, Lord Russell of Liverpool, and my noble friend Lady Lister about the child rights impact assessment. I hope she will address that issue in her response on behalf of the Government. I know that she will give examples, but I also hope that she will reflect further on looking at the fee-waiver rules on destitution. “Destitution” implies that one must be in a pretty desperate state before receiving any assistance. The figures on the numbers of those getting the waiver appear to bear that out. No doubt the Minister will give examples in her reply—without indicating who she is talking about or anything like that—of the kinds of situations and income levels to which those fee-waiver rules have been applied up to now. At least then we could get a feel for the issue.

 

The answer given on why there had been no public consultation rather took my breath away. Apparently, it was because there was a manifesto commitment to £600. That seems an extraordinary reason for saying that there will be no opportunity for people to comment on what the Government are doing in the sense of how it will apply and its impact. I would have thought that any Government would want to put something like that out for consultation to get responses from people on the impact of such a doubling of charges.

 

I was very surprised to find that we have a Government who believe that they should not do any further consultation on the impact of something—not the principle of whether they will do it—and on how they might mitigate that because of a figure in a manifesto that they intend not to keep but to put at a lower level than is in the manifesto, which I am not complaining about. However, if the argument is that people voted for an increase in the charge to £600—it is difficult to believe that votes in the general election were determined solely by that—then they have not got what they voted for because the charge is less than that. Again, I am not complaining about that. I find it extraordinary that that was used as a reason for not consulting and giving people an opportunity to comment on the impact on certain people of doubling the charges.

 

I raised the issue of the child rights impact assessment. As I said, I hope the Minister will address that in her response. I will bring my comments to a conclusion. We opposed this matter in the Commons, where the order was agreed to in a vote. I tabled my amendment today to emphasise our continuing serious concerns about the impact of this increase in the immigration health charge but it is not my intention to press it to a vote.

Before the noble Lord sits down, will he reconsider withdrawing his amendment? I honestly think that the Government have got this completely wrong. That is the mood of the House. Therefore, he might get considerable support.

I thank the noble Baroness, Lady Jones, for that contribution, but I have to say no; I am not prepared to reconsider the decision not to push it to a vote. We made our intentions clear beforehand and I have no intention of going back on what was said about pursuing this to a vote. However, I appreciate where the noble Baroness is coming from.

 

I hope that the Minister will read through this debate—I know she will, she does it automatically—because questions have been raised and, inevitably, she has not been able to respond to them all. I hope she will look at that and respond to ones she has not been able to reply to at the Dispatch Box. She has replied to a great many questions.

 

I also hope the Government—this pursues the point the noble Baroness, Lady Jones, made—will have got the message that there is a good deal of disquiet about the impact of doubling this charge in particular areas, not least in relation to children and school shortages. I hope the Government will have got that message and will look at this again when they come to their White Paper on the future immigration system. We have to await the chief inspector’s report on Home Office fee levels and see what that says; it may or may not make a comment on the charges we are talking about. I will leave it in that context and I beg leave to withdraw the amendment.