§ Mrs. Gwyneth Dunwoody (Crewe)
I beg to move,That an humble Address be presented to Her Majesty, praying that the National Health Service (Charges to Overseas Visitors) Amendment Regulations 1983 (S.I., 1983, No. 302), dated 3rd March 1983, a copy of which was laid before this House on 11th March, be annulled.
§ Mr. Speaker
With this, it will be convenient to discuss the second motion:That an humble address be presented to Her Majesty, praying that the National Health Service (Charges to Overseas Visitors) (Scotland) Amendment Regulations 1983 (S.I., 1983, No. 362), dated 8th March 1983, a copy of which was laid before this House on 11th March, be annulled.
§ Mrs. Dunwoody
When someone creates an enormous machine to crack a tiny nut, one is entitled to inquire as to what is behind the reasoning of the politicians concerned. Only a short time ago we debated the issue of charges to overseas visitors for National Health Service treatment. When Her Majesty's Opposition pointed out that such charges were unacceptable, we were told that the Opposition were not prepared to look for ways to raise cash for the National Health Service and that we had misinterpreted the intentions of Her Majesty's Government on what was, after all, only a good housekeeping measure. The Opposition might sometimes be mildly unfair to the Government. Is it true that the Government put forward a punitive measure against overseas visitors because they are prejudiced or because they suffer from latent racialism? Are they trying to demonstrate some obvious abuse of the National Health Service? I think not. We are told that the Government have seen in this measure a means of raising £6 million for the National Health Service and that it should be widely welcomed.
In the debate on National Health charges to overseas visitors, the Minister for Health said:We suspect that £6 million is, therefore, a reasonable expectation … If we get £6 million or anything like it, that will be a welcome addition to NHS funds … I therefore cannot understand why foreign visitors … should not make a modest contribution to their own care when they are taken into hospital and are able to pay."—[Official Report, 7 February 1983; Vol. 36, c. 725.]The scheme is manifestly unworkable. It is clear that that £6 million is disappearing further and further over the horizon. Are we really discussing a welcome addition to National Health Service funds, or are we discussing a £6 million con, what might be called the disappearing case of the suitable finance? If we accept that the Government do not seek to cause difficulty with non-whites who will be deeply offended by the questions asked of them when they go to National Health Service hospitals, we must accept the Government's suggestion that the charges are a means of raising cash. If that is so, it is about time they demonstrated that they are capable of raising cash through this absurd measure.
§ Mr. Andrew F. Bennett (Stockport, North)
Will the Minister tell us precisely how much the Government have received as a result of the measure? In evidence to the Select Committee on Social Services, the Minister's civil servants made it clear that the sum was only 25 per cent. of the estimates and they had grave doubts whether the measure would bring in very much more money over the next 12 months.
§ Mrs. Dunwoody
The Government are proud of their good housekeeping, and so, of course, they must be able to tell us how much they had raised. They tell us that they introduced the charges not through sheer bigotry or because of a narrow political point but because they believed it was a method of raising money for the National Health Service.
Overseas students are strongly affected by the measure. The debate should involve not only the Department of Health and Social Security but the Foreign and Commonwealth Office. What will the Foreign and Commonwealth Office do about those students who are funded by the British taxpayer? I tabled questions to the Foreign and Commonwealth Office asking what would happen when it was required to pay insurance for those students visiting Britain to receive tuition either as guests of the British Council or as straightforward students. I was told that the Government do not take out commercial insurance but bear the risk directly. I was told that there was no need to deviate from normal practice in this case.
On the issue of paying the hospitals directly for any cost incurred, the then Minister for Overseas Development replied:It is difficult to make a firm estimate of the costs of such treatment. Experience indicates that aid-funded students, who are medically examined before coming to Britain, normally have a good health record whilst in this country and I should not expect the annual cost of hospital treatment to exceed £100,000."—[Official Report, 14 December 1982; Vol. 34, c. 81.]If we are talking about overseas students and a book-keeping exercise that takes money from the Foreign and Commonwealth Office to give to the NHS, how much are we talking about? The FCO says that the sum is less than £100,000. It has said that it will not take out insurance for the students and that it will pay the costs direct. The estimated total is £100,000.
Let us be generous. Let us assume that the FCO is not very good at arithmetic — it has one or two minor problems—and that the total will be £200,000. That is not a viable sum and it comes nowhere near £6 million.
From what sources will the money be raised? The list of exempted countries includes EC countries, and there is a growing list of other nations that have reciprocal agreements with the United Kingdom. One of the countries on the list that we are discussing is Finland. It is obvious that fewer and fewer people will have to pay these charges when they come to Britain. Nevertheless, there will be costs to the NHS.
The Minister says that he will not keep the revenue statistics centrally as that seems an unnecessary extra burden to place on the machinery. In the debate to which I have referred, he made a number of statements on the keeping of statistics. He said:I have no intention of organising a massive statistical collecting operation, which would merely impose a higher administrative cost. I cannot imagine that most regional health authorities have the spare management time to indulge in a close scrutiny of the monthly revenue returns". —[Official Report, 7 February 1983; Vol. 36, c. 725.]It is obvious that he does not know how much is being raised by the charges, and he is making no effort to monitor the results. It might be embarrassing for him to do so.
It is not only Select Committees that are taking evidence that suggests that the regulations, far from raising money, may be costing money. In The Observer of 27 March 1983, under the headingNHS hit by failure of foreign fees",826 we are told that hospital administrators who have been charging overseas visitors since last October have found only a handful of patients to be ineligible for free treatment. The Royal Free hospital — it is an 840-bed hospital in north London—raised only £167 by making these charges. The Royal Liverpool hospital — a teaching hospital—has managed to raise £71. The Royal Free hospital found only eight of 8,000 new patients to be ineligible for free treatment. The Queen Elizabeth hospital in Birmingham, which has 618 beds, has raised £449.
The Ministry is not prepared to produce accurate statistics, and so we have to use the evidence that is available. However, it appears that vast sums are not being produced for the NHS. If the measure is not meant to fill the NHS's coffers, what does the Minister intend to use it for? Is he convinced that every NHS hospital is operating correctly the extraordinarily top-heavy machinery? Is he convinced that all the patients who might be caught by the measure are being informed at an early enough stage of what is likely to happen to them? Unless they are suffering from the plague, anthrax or other interesting diseases, it is obvious that they are at considerable risk of suddenly finding themselves landed with a large bill.
Patients arrive at our hospitals and they are not always clearly informed of their rights. If they have been admitted following an accident or emergency, they are not always aware of the likelihood that they will be charged for their treatment. They then find themselves in the frightening position of being asked for an incredible extra sum. It is clear from some of the cases taken up by the Joint Council for the Welfare of Immigrants that a number of people have already had uncomfortable experiences, to put it no higher than that.
Occasionally, patients have been admitted having been told that they are eligible for free treatment, only to discover when about to go in for an operation that they will be required to pay. One patient was not asked to pay until she returned to the hospital for a second course of treatment, when she was asked to pay about £1,000 for the first course of treatment. A number of people w ho have disputed charges have been convinced that they have been illegally charged.
Why has the Minister not so far sent out a new set of regulations following the House of Lords decision which changed the definition of people "ordinarily resident" in this country? Will guidance be given following the moves that have been made, for example, by the Department of Education which have made it clear that students will not be caught by much of this legislation and that if they find themselves faced with bills which they are unable to pay they will probably not be liable for the sums for which they are being asked?
These measures are not providing but costing the NHS money. All staff who are likely to need to interview patients at any point must be trained in what is called the stage one procedure. No hospital administration can run the risk of having a member of staff who does not understand the implications of the new procedure and does not pose the necessary question. If administrations are overwhelmed, they will need to employ additional staff; and there seems to be no regulation to cover that. It is clear that there will be differences in charges in NHS hospitals in which there are private wards. At present, private patients are being charged at one rate, but NHS charged patients—who will be a totally different category—will 827 be charged in a different way, sometimes having to pay more than private patients in the same hospital. That is not only bizarre but is totally unacceptable.
Consider the time it must take to implement all this machinery. One Sheffield hospital interviewed vast numbers of people and in the end raised from 30 patients £4,000. The comment from that hospital was that no particular problems had been encountered with stage one interviews—which take perhaps 45 seconds per patient —and that there had been no disruption to clinics. It was added, however, that there was occasional adverse reaction from patients. I wonder who those patients were —those with white skins? It was further added that stage two interviews could take up to 30 minutes, and other hospitals have agreed that it is a larger and more complicated interview at stage two.
What will happen when we reach that complicated interviewing stage? It is clear that the staff concerned will not only have to record every stage of the interview but will have to keep separately any complaints, at the request of the Minister, and that that will add considerably to the time taken administratively in dealing with disputes between patient and hospital. After all, the Minister has made it clear that the DHSS has no intention of acting as adjudicator in any argument where a patient feels that a wrong charge has been made; he has spelt that out in considerable detail. So, in addition to the extra expense and training, there will be additional printing costs and other overheads.
Most hospitals now, irrespective of the number of foreign visitors that they are likely to receive, not only print full guidance notes for their patients but have translated them into a number of different languages. Immediately, we get considerable anomalies within the system.
What about the recovery of bad debts? Within the NHS there does not seem to be an obvious way in which those who do not pay the considerable amounts of money that they might be asked to pay are submitted to any recovery procedure if they do not have the money on them on that occasion. There is no system of recovery of debts.
We now know that we are not talking about a means of making money or simply about an administrative change. We may not even be talking about the prejudices of the Conservative party. What we are talking about is the setting up of a very large, very bureaucratic and very considerable charging procedure within the NHS. I think that I and my hon. Friends who have been so worried about the effect upon individual patients when at the hospital they might be subjected to considerable inconvenience by embarrassing questions have perhaps missed the real reason why the Government are pushing so hard for the extension of the charging procedure. What the Government want to do but are not prepared to make public before the general election is to create a charging procedure that could be used throughout the NHS after a general election, if by some dreadful mischance the Government are returned to power, to charge ordinary patients for straightforward services.
It does not matter whether we are talking about X-rays or maternity services. No matter what the service, until the charges were introduced there was no easy way of hiving off particular services. Now it will be simple for any Conservative Government to say to people, "Of course, 828 we are terribly sorry. We know that you wanted an NHS that was funded out of taxation, but in the difficult economic situation that we face we think that it is much better that we should have a system of charging for individual services." That will be possible under this enormous bureaucratic machinery.
After all, let us ask ourselves why a Government who are calling in a member of the Sainsbury group to do a management exercise on a service that has had so many management surveys that they are coming out of its ears suddenly decide that they want on the one hand to have the administration simplified and to see whether it is working efficiently and on the other hand to create an enormous charging procedure that they say is to be used only against overseas visitors.
Never since the debate began has the Minister come to the House and said, "We can demonstrate an enormous abuse of the NHS." We heard a lot about it at the last general election, but there have never been any statistics or proper figures. It has never been clear that the NHS was being abused by those who came from abroad. Even the working party that is being used as an excuse for all this found out that under 1 per cent. of the patients that it looked at were in any way likely not to be eligible for free treatment. If that is so, there has to be a different political reasoning behind the regulations.
Nothing escapes. I am glad that we are including in the regulations a charge for a barium enema. That is a sensible way to describe the entire regulations. It is not anything to do with economics, it is not anything to do with raising cash for the NHS and it is not really anything to do with improving the facilities for those who come here, who might be taken ill and who might need to use the NHS. The regulations for England and Wales and those for Scotland are a demonstration of the most appalling prejudice, spawned in bigotry and unacceptable. I ask the House to reject them.
§ The Minister for Health (Mr. Kenneth Clarke)
The speech of the hon. Member for Crewe (Mrs. Dunwoody) had only a very tenuous relationship with the narrow terms of the regulations. For reasons which I quite understand, she took the opportunity to restate her well-known opposition in principle to a policy which was approved by the House last summer and which we began to introduce in the autumn.
As I understand that the Opposition are contemplating voting against the regulations, I shall begin by pointing out what they are about. First, they introduce the consequences of a very welcome reciprocal agreement that we have with Finland. Finland is now added to the list of countries whose visitors are not charged, because British visitors will not be charged in Finland in similar circumstances.
Secondly, the regulations also put up the rates by which we charge overseas visitors who are not eligible for free treatment. Contrary to the hon. Lady's assertion, there is no magic about the figures. The increase in rates of charges for overseas visitors is exactly in line with the increases that we have made in the charges for British private patients in National Health Service hospitals. We charge overseas visitors slightly more for outpatient treatment, because, where there is an outpatient consultation with a British patient who is paying privately for the services, it is expected that the consultant will make 829 a private charge, and the hospital does not benefit. In the case of overseas visitors, it is thought right that the hospital should make a charge for the medical services as well. Other than that, the charges are in most cases absolutely identical to the charges made for British patients who have private hospital treatment. I hope that no hon. Member would claim—when carried away with zeal for opposing the whole principle of charging tourists for their treatment —that we should charge Americans, Arabs and other overseas visitors less than we charge British people who choose to go into private wards.
The hon. Lady drew from the increase in charges the general point that this is some secret way by which we are preparing to launch charges on all British subjects for NHS treatment. The hon. Lady has put forward that argument before and keeps returning to it, but it is nonsense. It is unbelievably far-fetched. If she thinks that we need this policy in order to draw up the scale of charges, I can merely repeat that we already have a scale of charges—the charges that are imposed on British people who exercise their undoubted right to pay for private treatment in NHS hospitals. To believe that this minor measure has any connection with any threat to the NHS is to take the conspiracy theory to extreme lengths.
I will restate the policy in simple terms. It seems entirely fair and sensible that we should charge overseas visitors who come to this country for health care that they require here, except in the case of visitors from EC countries or other countries with which we have reciprocal agreements. We will, of course, always give anyone emergency treatment or treatment for various kinds of infectious diseases. However, when people come from countries with which we have no reciprocal agreements—countries in which British visitors would expect to have to insure themselves or to pay for treatment—it is not right that British taxpayers should meet the full cost of their treatment. It is only sensible that they should be expected to insure here and make some appropriate contribution towards covering the costs of the NHS treatment that they receive.
I was not quite sure what tack the hon. Lady was on this time. In previous debates, she has opposed the whole principle of charging, root and branch, and purported to see appalling issues of principle within it. Today she seemed at times to be complaining that we were not getting enough money out of the policy —that we should withdraw it because it was not producing the sums of money that we had suggested, when we debated the regulations last July, might possibly be raised.
§ Mrs. Dunwoody
If the Minister is in doubt, I will put it in simple terms. The Government's only justification for all these provisions has been that they will raise money. That is not the case. The Minister cannot prove that money will be raised, and that is not his intention, so why does he not come clean?
§ Mr. Clarke
The purpose of the policy was to charge overseas visitors to this country in circumstances in which British visitors to their countries would expect to have to pay for health treatment. Of course we expect it to raise money, and we made some estimates last summer as to how much might be raised.
As the hon. Lady knows, however, it is far too soon to have the slightest idea as to how much will be raised. The policy did not become effective until October last year. 830 That was when the charges became collectable, but for understandable reasons, due to the strike, the management of many hospitals was not ready to implement the policy fully. The hon. Lady mentioned the Royal Free hospital. The policy was not introduced there until mid-December, so it has been in operation for only three months or so, at a time when we have the fewest overseas visitors. We all work in London and it should be within the knowledge of us all that the number of overseas visitors on the streets of London rises markedly in the summer compared with the number here in the middle of an English winter.
It is far too early to start collecting full and accurate statistics, but we shall have them by the end of the year. It remains our hope that substantial sums will be raised. I trust that the Opposition will not be disappointed if that is the case, because any money collected will be spent in one way only—to cover the cost of the care given to the overseas visitor and thus to release resources for the improvement of patient care in the National Health Service. I hope that a substanital sum will be raised.
When we discussed this last summer, we gave broad estimates and explained the basis of those estimates. The working party sample showed that, as the hon. Lady has said, fewer than 1 per cent. of overseas visitors would be liable to be found ineligible for free treatment. We always knew that. It was estimates of that kind that produced the figure of £6 million if we were lucky. There are 5 million visitors to this country in the tourist season. If the working party sample was correct arid those visitors make the same use of the hospital services as the indigenous population under the age of 65, and if 0.8 per cent. of them are found to be ineligible for free treatment—
§ Mr. Clarke
The hon. Gentleman cannot show that it is wrong. The Opposition may have a point later in the year, but at present they are racing to make a case that they are incapable of proving.
§ Mr. Clarke
I will give way in a moment. I cannot give way while I am being constantly barracked from a sedentary position by another Opposition Member. I will give way to those who stand up rather than to those who remain seated, but I will deal first with the last sedentary interruption.
The estimates of revenue to be raised were based on the very calculations used by the hon. Member for Crewe. If the 0.8 per cent. of visitors found to be ineligible for free treatment make the kind of use of the hospital service that one would expect people of that age to make, up to £6 million might be raised. We do not know. We shall find out. We think that the basis for charging overseas visitors is fair. The more money that we can raise in a fair and proper way, the more will be available to improve patient services in this country.
§ Mr. Andrew F. Bennett
How many of the 5 million visitors come from countries with reciprocal agreements?
§ Mr. Clarke
Of course I know. The hon. Member for Stockport, North (Mr. Bennett) has attended these debates 831 before, but he does not have all the figures in his head any more than I do. There is an entire working party report on the subject.
My recollection is that the 5 million excludes EC visitors. I do not remember how many visitors from countries with reciprocal agreements are excluded. We set out in the clearest terms the way in which the estimates were made when we debated the matter last year. Of course we are not charging EC visitors or visitors from countries with which there are reciprocal agreements. We are charging Americans, Australians, New Zealanders, Arabs and others who were often surprised to hear in the old days that they did not need to take out medical insurance when they visited this country. Those people expect to have to take out such insurance when they visit a country which does not have a reciprocal agreement with their own and they have perfectly good money to pay towards the cost of their treatment here.
We hope that we shall raise a reasonable amount of money. When I am pressed about why I am not able to give figures, my response is that, first, I shall not waste a great deal of time and effort in the Health Service collecting monthly figures to try to support the Opposition's case. Secondly, the scheme only started in the autumn. We have only had the experience of a few months when there are not many overseas visitors here and nobody has had time to put in proper returns. Later in the year, when we have a had a full summer, we shall have the full year's figures. We shall then see to what extent we have managed to raise some useful cash—it will not be a great amount—with which the Health Service could well do.
§ Mr. Terry Davis
The Minister has fairly said that he is speaking from memory. As he will want to be fair to the working party which the Government established, will he confirm that the £6 million was calculated not by the working party but by the Government? The working party only estimated the number of people who might be liable to charges. We told the Government at the time that the Minister was using faulty assumptions when calculating how much money would come from this new procedure.
§ Mr. Clarke
We used the proportion of the sample that the working party took who turned out to be ineligible for payment. We assumed that that might prove to be the proportion. I could not care less what the eventual sum is. As usual, the hon. Lady went miles over the top when making her point. It does not matter how much we raise. The more we raise, as long as it is raised fairly and properly from people who expect to pay and can insure to pay, the better. We hope that we raise the right proportion from overseas visitors who are not entitled to free treatment. It is no good the Opposition hoping that we do not raise much in the hope of scoring some rather peculiar point from last year. We shall raise as much as we can, but we shall only know how much when we have the tourist season and a full year's operation behind us. I hope that we raise a reasonable sum of money.
§ Mr. Terry Davis
Is the Minister seriously telling the House that he does not care whether it costs more to collect the money than is received in revenue?
§ Mr. Clarke
If the hon. Gentleman had listened to what I said, he would know that I said nothing of the kind. 832 I said that how much we raise does not affect the principle. I hope that we raise a reasonable sum of money. If we raise £6 million, I shall be satisfied. I have never said, and I cannot understand how on earth the hon. Lady or the hon. Member for Birmingham, Stechford (Mr. Davis) can argue, that the cost of collecting this money will exceed the revenue. I simply do not believe that and she has no basis for saying it. No costs are being inflicted on the NHS. The idea that the modest sums that we shall raise will be outweighed by the cost of raising them is preposterous and I challenge the hon. Lady to produce any evidence to support it.
It is said by those who criticise the policy that we have introduced a new system of questioning which involves a great deal of additional work. We have introduced one extra question into the routine questioning of all overseas visitors who are admitted to hospitals. When one produces figures and tries to use them to show, for example, that a hospital has asked thousands of questions in a few weeks, that only means that each patient is asked questions such as his or her name, address, where he comes from and the other routine questions that are asked on admission. We have added a question,Have you been living in the United Kingdom for the past 12 months?It is absurd for the hon. Lady to say that that is causing vast additional expense and difficulty. All of our staff are perfectly capable of asking that one question without the difficulty or expense that the hon. Lady claims will exist. She said that few people have to go to the second stage. Of course, we always said that. We thought that less than 1 per cent. would turn out to be ineligible. Therefore, very few people must be asked the slightly more difficult questions in the second stage. The hon. Lady's arguments about how few people are found to be ineligible can be turned against her when she argues about the cost of the policy. She said that the results at the Royal Free hospital were disappointing. The hospital has had to ask the second-stage questions of only eight people during three months. [Interruption.]
§ Mr. Clarke
I shall not give way, because the hon. Lady is pleading with me to answer her question. How can she claim that the fact of those eight people being asked the second-stage questions produces enormous and insupportable costs for the Health Service that outweigh the value of the charges that it may recover? I know that the hon. Lady is fond of being rude to third parties, but she is larking about to such an extent that she is cutting out from the debate other hon. Members who have a constituency interest.
§ Mrs. Dunwoody
The Minister must add up the cost of the first-stage questioning in the additional training and wages of administrators. The Government are so frightened of overheads in the National Health Service that they have brought in yet another of their tame investigators, but the Minister says that this does not matter.
§ Mr. Clarke
If I am prepared to wait for the evidence of how much money we shall raise —I shall reserve judgment on that —the hon. Lady must accept the evidence that disproves some of the points that she made last summer about much more work being caused.
833 The report of the Royal Free hospital expresses disappointment at the very small sum that has been raised, but it also states:The considerable additional work originally envisaged has not materialised.I know of no hospital that is claiming that the enormous difficulties that were feared, largely because of the Opposition's campaign last summer, have materialised. They are asking this additional question of many entrants—
§ Mr. Clarke
Yes, it is asked of all patients, comparatively few of whom were overseas visitors ineligible for free treatment. But the idea that the additional question that we have asked to be put to all patients admitted to hospital costs a vast sum of money, and outweighs the revenue raised, is preposterous and is not borne out by evidence.
I am glad that the hon. Lady did not pursue the stronger and more worrying complaints that some of her hon. Friends made last year. They envisaged racism, discrimination between patients and hospitals turning away people who needed serious treatment. She knows that there is no evidence of that happening, although, unfortunately, some of her hon. Friends—who belong to organisations such as the one with the unlikely and rather alarming title "No Pass Laws to Health Campaign"—continue to insist, with no evidence to support it, that racism is implied in the policy. We gave advice to ensure that the risk of racial discrimination, which existed previously, was eliminated. We also asked all authorities to note seriously any complaints, and we shall receive reports of complaints. Although I know of no such evidence, I assure the House that if there is evidence that people are asked discriminatory questions, we shall step in to stop it.
There has been a problem with students, because, as the hon. Lady said, since we introduced the policy last year a case in the House of Lords has altered the previously understood definition—or the one followed by many Government Departments—of those who are ordinarily resident in this country. Such people are entitled to free hospital treatment regardless of other circumstances. My right hon. Friend the Secretary of State for Education and Science has already made a statement to the House about the way in which his Department is considering the implications of that judgment for overseas student grants. We are considering its implications for this policy, and we shall issue fresh guidance to authorities, making it clear that we must adopt the ruling of the House of Lords on who is ordinarily resident here. It may well ease the effect of the policy on patients.
Apart from those matters, the policy is working reasonably well. There have been some complaints, but none of them shows that the policy is basically wrong. All have been investigated, and the origin of the complaints shows no racial bias. The money raised by the policy has not been great, but the reason is that we are still in winter and the policy has just started. I hope that we shall raise a reasonable sum of money, but only by making proper charges to those who expect to pay, or who insure against such an eventuality, when they come to Britain.
The House should unite and say that it hopes that, in this reasonable way, a decent sum of money is raised for 834 the Health Service. Attempts to found on this routine order a case that we are, in a sinister way, trying to prepare the ground for abolishing the National Health Service and that we shall discriminate against people of the wrong colour, show xenophobia, or impose intolerable burdens on the Health Service are ridiculous. I hope that the House will pass these routine regulations without a vote.
§ 11.5 pm
§ Mr. Edward Lyons (Bradford, West)
If someone from this country goes on holiday to America, he can easily obtain holiday health insurance, but. as the Government ought to know, such insurance is virtually unknown in the Third world. Accordingly, someone coming from the Indian subcontinent or one of the developing countries cannot obtain such insurance, assuming—in the absence of publicity—that he knows of the change of law in Britain.
In Britain there is no facility for obtaining health insurance for overseas visitors. The one Indian and one Pakistani company that operate here do not provide health insurance for holidaymakers, nor do their offices in the subcontinent. Therefore, the Government have not legislated for the fact that in practical terms it is not possible to obtain health insurance.
Consequently, on suffering an accident, a person from such a country—incapable of being insured—suddenly faces enormous bills. People from the Third world seldom have the money to pay £86 or £90 a day for a hospital bed, and the Government know that. As a result, the host or a relative or friend of the visitor signs a document before the person is admitted to hospital stating that he will be responsible for the bill.
The visitor cannot pay the bill because there is no way he can and there is no way he can be insured. Instead, British citizens who act as hosts, or feel an obligation to ensure that a friend gets proper medical treatment, must pay.
Such friends living in Britain have no insurable interest in law for visitors and, therefore, cannot obtain insurance. Section 7 of the rules that were passed last year states that the person liable to pay the chargesshould be the overseas visitor who is the recipient of the medical services".Yet, with regard to many of the people who come here, that is absolute nonsense because our hospital charges are totally beyond their ability to pay, especially if they remain in hospital for any length of time.
Effectively, in the context of the developing countries and the Indian subcontinent, these regulations are virtually totally ignored. Instead of getting the money from the patient, the hospital asks someone else to be responsible. Those people, many of whom scarcely understand English, do not know what they are letting themselves in for, and in any event do not have the resources to pay when suddenly confronted with a colossal bill. The area health authority must then sue, but by doing so it could push such people—say, a bus driver and his wife whose visitor sustained a bill for £5,000—into bankruptcy.
In that sense, the purpose of the regulations is to get money not from the visitor but from British citizens, if necessary by pushing them into bankruptcy.
I can give an example of what I mean. In Bradford, before the rules came in on 1 October last year, a man called Sharma came from India to visit his sister Mrs. Joshi, who was married to a bus driver in Bradford and 835 lived in Hampden street. There was no insurance because in any event the rules were not in operation when he came into the country. He then fell on black ice, broke his thigh and was in hospital for 53 days. The bill was £4,628.
One might have thought that the Government would have said at once that as the man was here before the new rules came into operation, they would not press for payment. The health authority said at first that it would look for payment to the patient, who had no possibility of being able to pay. It then turned out that the health authority had taken the precaution of getting his sister, the host, to sign an agreement saying that she would be responsible.
§ Mr. Lyons
In due course the bill was presented. On 7 February I wrote to the Secretary of State telling him of what had happened, and waited for a reply. Eventually, I sent a reminder, and now, late in April, over two months have gone by and my letter has not merited any reply.
If one were to pursue a visitor back to his country of origin in a poor country, a developing country or one in the Third world, there would be problems. Usually, the patient will not have the money. Even if he has, court proceedings there are far longer even than in Britain. Although health authorities are encouraged to follow the debtor patient back to the country of origin, the cost to the British Treasury of seeking to recover that money will be far greater than any possible amount recovered.
§ Mr. Kenneth Clarke
The case that the hon. and leaned Gentleman gives is a worrying one, but I can answer his questions. The Government have given no advice to any hospitals to look to anybody other than the patient for charges. The only exceptions are in the cases of people working here from aeroplanes or ships, where the ship owner or the airline company may be liable. Otherwise, the only person liable is the patient. No advice has been given to health authorities to seek undertakings from relatives. The health authority in this case says that the sister volunteered the undertaking. The hon. and learned Gentleman kept saying the the Government had said this or that, but the Government have told nobody to collect money from relatives, and will not do so. We have told the health authority not to pursue the lady in question for the money.
§ Mr. Lyons
I am delighted to hear this, although I feel that it would have been rather more gracious, and therefore better received, if I had not had to wait for two months for a reply. To get the reply I have had to make a speech.
The structure of the regulations is absurd. The Government know that many visitors who come here are coming to visit members of the ethnic minority population settled here. They know that there is no insurance structure by which such people can come within the law. When I appreciated what the Government were doing, the first thing that occurred to me was that if the Government were to insist on charging, they would conduct an advertising campaign, or at least have notices in British posts abroad, and would notify foreign airlines and embassies, so that everybody could be warned of what would face them if 836 they had an accident in Britain. However, in the Third world and the Indian subcontinent, one cannot obtain insurance, so what would be the good of that?
That means that anybody of limited means who invites a guest here and is faced with that problem with his guest must consider one thing. The guest might have an accident or fall ill. The hospital, whether under instructions from the DHSS or not, will ask, "Will you sign this?" What is the host to do? Is he to say no? Such people are not aware what instructions pass between the DHSS and the hospital administrator. They will do anything that is required to get that person proper treatment. They often have no idea how long it will take the person to recover. He may be there for months. They do not know how much the costs will be. Obviously, they will elect to sign on the dotted line. If there were no intention to recover the costs from the relative, why did the Bradford hospital ask the relative to sign? They were asking not a business man but a housewife—an Asian housewife—to sign. That is not a very even contest.
I appreciate that the Government want to get as much money as possible for treatment, but they will either have to create some kind of insurance scheme or encourage some insurance company to create an insurance scheme whereby people from the Third world can get properly insured. Otherwise they will have to say that people from the Third world who cannot pay will have to be treated anyway, or they will die in the streets.
What will happen if a man is assaulted, perhaps because of his colour, when he is walking in the street? He will not be responsible. He might be left lying on the ground having been injured by a British citizen. What would such a person do about his hospital bill? According to the Government, and there is no exemption in the rules, he has to start paying about £90 a day for staying in hospital. He might have come to Britain only for a couple of weeks' holiday. Even general health insurance in Britain usually has a clause exempting the company from liability for treatment in the first three months and most holidaymakers are not away for three months. If the Government are to pursue the policy, they must bend their mind to what they will do with people from the Indian subcontinent, the Third world and poorer countries. The fact that for more than two months the Government did not answer the letter in which I raised some of these points shows that the Government do not have a clue what to do. That is why they could not answer the letter. For a large number of visitors to Britain, because the Government's scheme cannot work, it is completely absurd.
§ Mr. Bill Walker (Perth and East Perthshire)
The publicity that the speech of the hon. and learned Member for Bradford, West (Mr. Lyons) will receive will alert United Kingdom residents, certainly those in his constituency, to the problems that their relatives may face if they come to the United Kingdom in the circumstances which the hon. and learned Gentleman has outlined. I am sure that the hon. and learned Gentleman has done his homework and he will realise that there are insurance policies available if one wants to go to the trouble of finding them. If the cost of insurance is compared with the fare that is paid for a trip to Britain, one sees that the cost of insurance is relatively small. Individuals are prepared to pay a massive bill for air or sea travel compared with the small charge that would be made for insurance.
837 I welcome the presence in the debate tonight of at least three Scottish Labour Members. It seems that the events of the other evening when we debated another routine order in the absence of Labour Members have had results. However, it is rather interesting that there are no Scottish National, Liberal or Social Democratic Members from Scotland, although one of the orders that we are debating relates to Scotland. It just shows that they do not have much interest in what is happening to the Health Service in Scotland.
As my hon. and learned Friend the Minister said, this is a routine statutory instrument to increase the charges for visitors from countries with which we have no reciprocal agreement. It is only fair and just that such visitors should pay for their treatment and that they should normally do so by insurance. To suggest that insurance is not available in a country that leads the world in insurance is nonsense. The hon. and learned Member for Bradford, West will get plenty of advice from insurance brokers who, when reading his speech, will realise that opportunities exist for him to distribute information to the people who come to his constituency.
If British people embark on a journey to countries that do not have reciprocal arrangements, they must expect to take out an insurance policy. I am delighted to see that with almost 21 minutes to go in the debate the Scottish National party has decided to put in an appearance. When the ordinary British citizen visits the United States, he expects and is required to pay for any hospital or other treatment which he may unfortunately require. Why should not the British taxpayer expect visitors from the United States, Australia, and New Zealand, or rich Arabs—who can well afford to pay—to take out insurance policies?
§ Mr. Walker
For the benefit of the hon. Member for Crewe (Mrs. Dunwoody), may I say that in the days before package air travel was readily available to the masses—such as those who came from the Indian subcontinent—the number of overseas people involved in using our National Health Service was tiny, but that number is increasing year by year. I am talking about many hundreds of thousands of visitors from countries which do not have reciprocal arrangements. Those countries—such as Finland—may deem it advantageous to enter into reciprocal arrangements because of the publicity that is given to visitors to this country. Why should British taxpayers be expected to foot the bill for individuals who can afford to pay the cost of air travel to the United Kingdom?
If a Scot visits the United States on a skiing, climbing, sailing or gliding holiday and is unfortunate enough to require hospital treatment, he is expected to have taken out a policy to cover such an eventuality. If an American citizen visits Scotland for climbing, sailing and gliding —I do not think that many visitors come for the skiing, other than for competitions — I would expect him, rightly and properly, to take out an insurance policy, as I and my family must do if we go abroad.
As to the charges in Scotland, I do not believe that a charge of £26.90 for one day—
§ Mr. Walker
If the hon. Gentleman looks at the base of column 40, he will see the figure of £26.90 The cost ranges from £26.90 to £127.90, depending on the room, for one day. I do not consider, at whatever end of the scale we look, that these charges are unreasonable because that is what should be charged. To suggest that to answer one additional question is an encumbrance upon the National Health Service is wrong. Anyone who has ever been involved in an admittance to a National Health Service hospital knows that the patient is asked no end of questions even if he is severely injured. However ill the patient is, all sorts of questions are asked. To ask one additional question does not seem to add considerably to the cost. I welcome the regulations.
§ Mr. John Maxton (Glasgow, Cathcart)
I am happy to speak after the hon. Member for Perth and East Perthshire (Mr. Walker). Despite what he says, I know that the hon. Gentleman would like a system of complete medical insurance to be introduced, because I remember him saying that recently in a Committee that debated these regulations. The Minister may not believe in that, but the hon. Gentleman certainly does.
§ Mr. Maxton
The hon, Gentleman believes that there should be American-style insurance schemes in this country. I have heard him say that, and he believes it.
§ Mr. Walker
On a point of order, Mr. Deputy Speaker. The hon. Member for Glasgow, Cathcart (Mr. Maxton) has made a charge that I completely refute. I never made such a statement.
§ Mr. Deputy Speaker (Mr. Paul Dean)
It is up to the hon. Member for Glasgow, Cathcart (Mr. Maxton) to decide whether to give way.
§ Mr. Maxton
I did not intend to give way to the hon. Gentleman because there is only a little time left.
The hon. and learned Member for Bradford, West (Mr. Lyons) made some good points, but he limited them to those from the Indian subcontinent and the Third world. Nevertheless, what he said is, to some extent, true of others. Many people have emigrated from Britain and married Americans, Australians and New Zealanders. Sometimes their young children return to stay with grandparents. During their visit, they may contract an illness. They may be covered by limited insurance. Indeed, all insurance schemes have limited sums attached to them. It is impossible to buy open-ended insurance. Therefore, there is always a cash limit.
One of my constituents, an elderly lady, took out health insurance for about £3,000 when she went to visit her son in the United States of America. Most people would think that an adequate sum to cover their health on a short holiday. However, while in the United States she suffered a stroke and was in hospital for 10 or 11 weeks. She had a major operation during that time and faced a hospital bill of about £60,000. Her son had been guarantor for her. He ran a small plumbing business in America, but he went bankrupt as a result.
839 That is the position in the United States of America, but the same thing could arise in Britain. It is all very well for the Minister to say that payment will not be demanded from relatives and friends, but that is not clear in the regulations. Where do the regulations say that they cannot go elsewhere? [Interruption.] I have read them, and a health board in Scotland could interpret them to mean that it could look for the money from someone other than the person involved.
§ Mr. Kenneth Clarke
In the documents that the hon. Gentleman is clutching, what is there that could lead a health board to that conclusion? Contrary to the assertions of the hon. and learned Member for Bradford, West (Mr. Lyons), there are no instructions to anybody to look to relatives for charges. In the case in which a mistake was made in Bradford, the Government have stepped in to ensure that it is not pursued and is stopped.
§ Mr. Maxton
If the Minister had listened he would know that I said not that there was an instruction to pursue but that certain boards, such as that in Bradford, could interpret it that way. In some cases, that has obviously happened.
The Government have set up this expensive rigmarole to get a few people to pay. It is a burden to those who have to pay, and it is unnecessary. It is all very well forthe Ministerto say that the system is not expensive, but a series of questions is asked. The Minister made great play of the fact that the Royal Free had interviewed only eight people. How many extra staff and how much training was carried out for that? What is the cost to the NHS of such nonsense?
We are witnessing high costs for a minimum return. Indeed, £500,000 is expected in Scotland as a result of the regulations. Will not that money be taken up by the cost of administration? Even when the health boards have that £500,000, there is no guarantee that it will not be taken away from them in other ways. This is and always was a petty measure. We should be saying to visitors that we have a free National Health Service and that, when they come to Britain, it will be free to them, too. That is the principle of the Health Service and it should apply to tourists as well.
§ Mr. Teddy Taylor (Southend, East)
It is outrageous for the hon. Member for Glasgow, Cathcart (Mr. Maxton) to spread bogus scare stories about what is said to be a complex scheme.
In the one minute that is left to me, which has now gone—
§ It being half-past Eleven o'clock, MR. DEPUTY SPEAKER put the Question, pursuant to Standing Order No.4 (Prayers against Statutory Instruments, &c. (negative procedure)).
§ The House divided: Ayes 53, Noes 114.841
|Division No. 133]||[11.30 pm|
|Alton, David||Dalyell, Tarn|
|Bennett, Andrew (St'kp't N)||Davis, Terry (B'ham, Stechf'd)|
|Campbell-Savours, Dale||Deakins, Eric|
|Canavan, Dennis||Dean, Joseph (Leeds West)|
|Cocks, Rt Hon M. (B'stol S)||Dixon, Donald|
|Cook, Robin F.||Dormand, Jack|
|Cowans, Harry||Dunwoody, Hon Mrs G.|
|Cunliffe, Lawrence||Evans, John (Newton)|
|Foulkes, George||Rodgers, Rt Hon William|
|Harrison, Rt Hon Walter||Roper, John|
|Haynes, Frank||Ross, Stephen (Isle of Wight)|
|Holland, S. (L'b'th, Vauxh'll)||Rowlands, Ted|
|Hooley, Frank||Skinner, Dennis|
|Hughes, Simon (Bermondsey)||Snape, Peter|
|Lyons, Edward (Bradf'd W)||Soley, Clive|
|McCartney, Hugh||Spearing, Nigel|
|McDonald, Dr Oonagh||Steel, Rt Hon David|
|MacGregor, John||Strang, Gavin|
|Marshall, D. (G'gow S'ton)||Wainwright, E. (Dearne V)|
|Maxton, John||Watkins, David|
|Millan, Rt Hon Bruce||Welsh, Michael|
|Mitchell, R. C. (Soton Itchen)||Williams, Rt Hon Mrs(Crosby)|
|O'Brien, Oswald (Darlington)||Wilson, Gordon (Dundee E)|
|O'Neill, Martin||Winnick, David|
|Penhaligon, David||Tellers for the Ayes:|
|Pitt, William Henry||Mr. Allen McKay and|
|Robertson, George||Mr. John Home Robertson.|
|Robinson, G. (Coventry NW)|
|Alexander, Richard||Lloyd, Peter (Fareham)|
|Alison, Rt Hon Michael||Lyell, Nicholas|
|Amery, Rt Hon Julian||Macfarlane, Neil|
|Ancram, Michael||MacGregor, John|
|Arnold, Tom||MacKay, John (Argyll)|
|Aspinwall, Jack||McNair-Wilson, M. (N'bury)|
|Atkins, Rt Hon H.(S'thorne)||Major, John|
|Baker, Nicholas (N Dorset)||Marlow, Antony|
|Beaumont-Dark, Anthony||Mather, Carol|
|Benyon, Thomas (A'don)||Mawhinney, Dr Brian|
|Berry, Hon Anthony||Maxwell-Hyslop, Robin|
|Bevan, David Gilroy||Meyer, Sir Anthony|
|Biggs-Davison, Sir John||Mills, Iain (Meriden)|
|Blackburn, John||Moate, Roger|
|Boscawen, Hon Robert||Morgan, Geraint|
|Boyson, Dr Rhodes||Morrison, Hon C. (Devizes)|
|Bright, Graham||Murphy, Christopher|
|Brinton, Tim||Myles, David|
|Brittan, Rt. Hon. Leon||Neale, Gerrard|
|Brooke, Hon Peter||Needham, Richard|
|Brotherton, Michael||Nelson, Anthony|
|Brown, Michael(Brigg & Sc'n)||Neubert, Michael|
|Bruce-Gardyne, John||Newton, Tony|
|Buck, Antony||Page, Richard (SW Herts)|
|Bulmer, Esmond||Percival, Sir Ian|
|Butcher, John||Prentice, Rt Hon Reg|
|Carlisle, John (Luton West)||Proctor, K. Harvey|
|Carlisle, Kenneth (Lincoln)||Rees-Davies, W. R.|
|Clarke, Kenneth (Rushcliffe)||Renton, Tim|
|Cope, John||Rhodes James, Robert|
|Cranborne, Viscount||Rhys Williams, Sir Brandon|
|Dorrell, Stephen||Ridley, Hon Nicholas|
|Dover, Denshore||Rossi, Hugh|
|Dunn, Robert (Dartford)||Shaw, Giles (Pudsey)|
|Dykes, Hugh||Shepherd, Colin (Hereford)|
|Fenner, Mrs Peggy||Sims, Roger|
|Fisher, Sir Nigel||Smith, Tim (Beaconsfield)|
|Fletcher, A. (Ed'nb'gh N)||Speed, Keith|
|Fletcher-Cooke, Sir Charles||Speller, Tony|
|Garel-Jones, Tristan||Stanbrook, Ivor|
|Goodhart, Sir Philip||Stevens, Martin|
|Goodlad, Alastair||Stewart, A. (E Renfrewshire)|
|Griffiths, Peter (Portsm'th N)||Stradling Thomas, J.|
|Grist, Ian||Taylor, Teddy (S'end E)|
|Gummer, John Selwyn||Thomas, Rt Hon Peter|
|Hamilton, Hon A.||Thompson, Donald|
|Hampson, Dr Keith||Thorne, Neil (Ilford South)|
|Hannam, John||Townend, John (Bridlington)|
|Hawksley, Warren||Trippier, David|
|Henderson, Barry||Waddington, David|
|Hogg, Hon Douglas (Gr'th'm)||Waldegrave, Hon William|
|Hunt, John (Ravensbourne)||Walker, B. (Perth)|
|Jopling, Rt Hon Michael||Warren, Kenneth|
|Lamont, Norman||Watson, John|
|Lawrence, Ivan||Wells, Bowen|
|Lester, Jim (Beeston)||Wells, John (Maidstone)|
|Wheeler, John||Tellers for the Noes:|
|Wiggin, Jerry||Mr. David Hunt and|
|Mr. Ian Lang.|
§ Question accordingly negatived.