§ 3.51 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Elton)
My Lords, with the leave of the House, I will now repeat a Statement being made in another place by my right honourable friend the Secretary of State for Social Services. The Statement is as follows:
"With permission, I should like to make a Statement about changes which the Government propose to make in the rules for use of the National Health Service by overseas visitors.
"My predecessor told the House last March of the Government's intention to make regulations to provide for charges for hospital treatment for those not ordinarily resident in the United Kingdom. The National Health Service is under pressure, with long waiting lists for some specialties in some parts of the country. It is only fair that people coming from overseas who have not contributed through taxes should be asked to pay for treatment which our own citizens would be required to pay when they are overseas. We have consulted widely on the proposals and I can now report to the House that, subject to some important modifications, we intend to implement these proposals with effect from 1st October.
"When our original proposals were announced two major fears were expressed. First, there was concern that the procedures might be complex to administer. Second, there was concern that, contrary to our intentions, the procedures used to identify chargeable patients could give rise to racial discrimination. The Government therefore decided to set up a working party representing a wide range of interests to advise us on how these difficulties might be overcome.
"I am grateful to the working party, and copies of their report have today been placed in the Vote Office. The working party found that the present rules are not being administered consistently or fairly. In particular, they thought there was a distinct risk that checks on eligibility may be being applied by many hospitals in a way which discriminates against members of ethnic minorities living here. I am satisfied that a new system can be introduced which will provide extra finance for the National Health Service, and which hospitals can administer in a way which will minimise the risk of racial discrimination. We therefore accept the 761 working party's recommendation that there should be a standard procedure for checking the eligibility of all new hospital patients and guidance will be issued to hospitals on the main principles identified by the working party.
"We propose, however, some further changes in the scope of the scheme. In response to representations that the proposals would bear hardly on overseas students here for a considerable period, we have decided that all visitors—including overseas students—should become exempt from charges after they have been here for one year, instead of the three years in the earlier proposals. We also propose that people coming here to work should be fully exempt from the beginning of their stay as will some visiting dependents of people settled in this country. In other respects the scheme will be broadly the same as that on which we consulted last year. We estimate that the charges will raise some £6 million in a full year. I should emphasise that the money will be available to the district health authorities or boards to finance their expenditure on health care.
"Reciprocal agreements with other countries will of course be fully honoured. We shall lay regulations before the House in due course. The new arrangements will be publicised abroad so that visitors coming here can take out insurance before they arrive, as we do when we visit their countries.
"In making these changes we will bring our position into line with virtually every other western country. There is no reason why the British taxpayer should provide free hospital treatment to short-term visitors to this country ".
That concludes the Statement, my Lords.
§ 3.55 p.m.
Lord Wallace of Coslany
My Lords, first of all, may I thank the noble Lord, Lord Elton, for the very comprehensive Statement that he has made. I cannot say, quite honestly, that I welcome this Statement, because the Statement indicates a major departure from the principle on which Britain's National Health Service was founded; namely, that all who fall sick within our shores should receive treatment irrespective of class, colour or creed, the parable of the Good Samaritan in practice. Speaking as one who was very much involved in the campaign to bring in the National Health Service in those days, that was the principle that activated us, in which we could set an example to the world.
I would ask the noble Lord: What evidence of abuse of the National Health Service has been produced to the working party or the Government to justify this move? The proposals will, incidentally, mainly affect nationals of poorer countries overseas; yet I understand that Common Market countries are to be exempt. I would like to ask the noble Lord, as he would expect, a number of questions. Does this affect the Republic of Ireland? How do the Government arrive at a saving of £6 million? Is this figure net or gross, bearing in mind that considerable administrative work will arise to hospitals and GPs, as all new patients—and this is a major departure—whether they are British nationals living in Britain or otherwise, will have to complete a form, and GPs in the main will be 762 responsible for these forms. it would appear that considerable work will now fall on GPs in referring people to hospital and the consequent filling in of forms.
My third question is: Will people resident abroad but in receipt of United Kingdom pensions be covered? Fourthly, while I am glad that the reciprocal agreements are preserved, will the Government publicise countries where such agreements exist? I am fully aware that leaflets are available, but the average person is not aware of this. I think the time has come when tour operators, operators of package tours and so on, should compulsorily provide the excellent leaflet that the department issues.
So far as students are concerned, naturally I and all of us will appreciate the reduction to one year. But I ask: Why one year for genuine students? It is quite conceivable during that year that a student may fall ill, particularly if he comes from a tropical country to Britain. What will happen to the student in that particular period?
My next question is: What measures will be taken to recover charges when the patient is unable to pay, bearing in mind the obvious difficulties that are already being experienced by some health authorities in recovering charges at present made for private beds in the National Health Service? Will there be an initial check on ability to pay? What will happen when a patient obviously cannot manage payment? I assume that the patient will be treated whether he can afford it or not.
Finally, the noble Lord said the regulations will be placed before the House. May I assume, therefore, that these regulations will be debated fully both here and in another place?
§ Lord Gladwyn
My Lords, we too would like to thank the noble Lord, Lord Elton, for repeating the Statement. We naturally welcome the concession which has been made in respect of overseas students—they are considerable concessions, certainly—but we still consider that the proposed contributions to the National Health Service during the first year of these students' residence here will bear very heavily upon them, more particularly in view of the highest fees in the world which they are at present suffering. Notably, it will affect very unfavourably those coming from the poorer Commonwealth countries. It also seems rather odd to us that total exemption will be allowed not only in respect of EEC countries, which is right and proper under the Treaty of Rome, but also to those coming from eastern European countries, notably the Soviet Union, while those from deserving Commonwealth countries, such as Malaysia or Kenya, will apparently be stung. That seems to us to be paradoxical, to say the least.
In view of the circumstances, and the fact that the new system will inevitably imply a larger bureaucracy, which is not denied, and that, as I understand it, other funded students will still apparently escape, thus combining to produce savings much less than even £6 million, why should not the Government go the whole hog and exempt overseas students altogether? That would seem the natural and reasonable thing to do. Finally, may I ask what happens if a student is admitted to hospital after an accident and cannot afford to pay?
§ 4.2 p.m.
§ Lord Elton
My Lords, I am not sure how grateful protocol requires me to be for the way in which noble Lords opposite have received this Statement, but I certainly take note of what they say. In reply to the noble Lord, Lord Wallace of Coslany, I would say that the National Health Service was not funded to provide free medical treatment for the entire population of the world. The noble Lord took the image of the Good Samaritan, but may I point out to him that the Good Samaritan was travelling along a road, where he met the victim; the victim did not deposit himself on the front doorstep in order to have his accident. The noble Lord asked what evidence we have of abuse. It is not easy to quantify evidence of abuse, but it is very clear, if subjective, from the mailbags of Members in another place, and indeed in letters that I myself see, that abuse does take place. Indeed, it takes place to the extent of a cost of £6 million net, and that is the gain which we expect to make in the National Health Service.
The original suggestions were, I believe, open to the criticism that they were complicated and therefore costly. That is one of the reasons why the working party was appointed. It produced a much simpler programme with two stages of identifying people eligible for exemption. The first is the universal challenge and consists only of three questions. If the answer to any of those questions is Yes, no documentary proof is asked for and that is the end of the matter. This is conducted in hospitals and not by general practitioners, as the noble Lord, Lord Wallace of Coslany, wished to be assured.
In respect of persons retired abroad, there will be exemption for charges in cases of immediate necessity, but for anything else, or thereafter, it will be a question of whether or not the person resumes residency in this country. As to the matter of students, it is a considerable concession—and most courses last three years, and some last four years—to exempt everybody after the first year. In the first year, the student, if he is a bona fide student, will have made arrangements before he comes here. He will have considered what his obligations will be and doubtless, if he is prudent, he will have taken out insurance just as your Lordships or your Lordships' children would if they went abroad to a country without reciprocal arrangements. On the matter of reciprocity, the noble Lord, Lord Gladwyn, asked why Russia was included in the reciprocal countries. I would add that I believe that the whole of the eastern bloc is included, because the whole of the eastern bloc has reciprocal arrangements. If the noble Lord were unfortunate enough to fall ill in any of those countries, he will get treatment free of charge, which is what his host would suppose was the equivalent of what the noble Lord would receive here, although I would recommend him to get home first if he can.
As to the question of recoverability, the recoverability of charges is a matter for the hospital authority; it is for them to recover those debts as it is for any prudent person to recover any debt if a person goes without paying a debt then the normal course will be pursued, and it will vary from country to country no doubt according to the conventions. I believe that I have answered all the questions which were raised. If I have not done so, I am sure noble Lords will remind me.
§ Lord Boyd-Carpenter
My Lords, might I ask my noble friend three questions on his most interesting Statement? First of all, will the charges be calculated fully to recover the cost of treating the individual concerned? Secondly, how does my noble friend and his right honourable friend propose to deal with the case of a person coming from a tropical country who develops a highly infectious disease which it is of great importance to us should be treated speedily, in hospital, in isolation? Is he satisfied that these arrangements will not deter that person from doing what is very much in our country's interests and getting quickly into hospital? Thirdly, will the noble Lord's right honourable friend continue to seek to negotiate reciprocal agreements with other countries that offer comparable health services? It is apparent that, if he does, he will lose a little revenue at home; but is my noble friend aware of the enormous value of these reciprocal agreements to those of our fellow countrymen who travel abroad? Will he give an assurance that his right honourable friend will still seek to negotiate reciprocal agreements when opportunity offers?
§ Lord Elton
My Lords, in response to my noble friend, on the question of the level of charges, they will be set at the same level as those for private treatment under the National Health Service when separate arrangements with the consultant have not been made. On the question of infectious diseases, the proposal is that all communicable diseases shall be exempt from charge. I believe that that answers the question. It might be worth adding that treatment in hospitals before formal admission—that is, treatment in accident and emergency departments—will also be free of charge.
As to reciprocity, I will certainly draw my noble friend's remarks to the attention of my right honourable friend. I have no doubt that he is already aware of the implications of this. The benefits of reciprocity will perhaps be more apparent to countries with which no such arrangements exist after the introduction of these arrangements than formerly they have been.
§ Lord Davies of Leek
My Lords, while thanking the noble Lord for his Statement and as someone who had privilege, when a junior Minister, of helping two or three countries to negotiate reciprocal agreements, may I ask whether the noble Minister is aware that this calculation of saving £6 million is going to create, or so it seems to me, a huge edifice of bureaucracy which in truth will not save £6 million at all for the country? Secondly, in view of the fact that more and more people are spinning around the world by jet on holidays, would he follow the advice of the noble Lord, who put it in the form of a question, to increase reciprocity agreements in many more parts of the world—particularly in South America and in the United States of America? Lastly, as a matter of history, did the noble Lord ever see that marvellous film "The Man Who Came to Dinner"? He was a good man who landed on the doorstep, and who not only fell once but who fell for the last time after he had been looked after for about 12 months; he was a good samaritan who deposited himself on his hosts' doorstep.
§ Lord Elton
My Lords, on the first point, I think that it might reassure your Lordships if I explained a little more what the process will be. On formal admission to the hospital a patient will first be asked, "Have you or your husband or wife lived in this country for the last 12 months? If the answer to that is, "Yes", then that is the end of the matter. The second question will be, "Are you or your wife living permanently or indefinitely in this country? "If the answer to that question is, "Yes", then that is the end of the matter. The third question will be, "Are you or your husband or wife in this country for the purpose of work?" If the answer to that question is, "Yes", then that is the end of the matter. That requires no enormous edifice of bureaucracy: it requires one intelligent and sympathetic person, and 1 am quite convinced that the National Health Service is able to produce him.
On the second point, I think that I have already replied about reciprocity to my noble friend. On the third point, it is a very long time since I saw the admirable film about the man who came to dinner. As I recall it, his accident was genuinely accidental, but if he deposited himself on purpose it was not with the intention of breaking various limbs in his body.
§ Lord Donaldson of Kingsbridge
My Lords, in relation to the question of students, can the noble Lord explain why people coming to work here are treated—I think, quite correctly—with exemption and students are not? Students are coming here to work and it seems to me that the Government have done so much damage already to students that they ought to be very careful about this matter. I should like to support the noble Lord, Lord Gladwyn, and the noble Lord from the Front Bench who spoke, in begging the Government to reconsider this matter.
The other point that I should like to make is simply that the main object here is to prevent abuse. Although I think that there is a lot of abuse outside the student world, I do not think that there is very much evidence of abuse within it. So the case is really quite strong. Finally, may I make the point that at last the savings which are expected to be made are not going to be snaffled by the Treasury, but are going to be given to the hospital boards. As regards that I fully congratulate the noble Lord.
§ Lord Elton
My Lords, on the first point, I think that I should say that no Government in this country have ever treated students as a special category under the National Health Service. Moreover, it is sometimes difficult to distinguish the bona fide student from the person who becomes a student in order to enjoy special benefits. If a person is here for 12 months only then I think that the noble Lord will see what I am driving at. As to the question of the savings remaining with the district in question, I am glad that the noble Lord shares our view.
§ Baroness David
My Lords, can the noble Lord give us an idea of the cost? If the overseas students were exempted for the first year as well as the later years of their course what difference would that make? Following up what the noble Lord, Lord Donaldson said, would such action be worth while for the promotion of 766 good feeling?—because we know what ill-feeling has been caused by the full cost fees for overseas students. Would this not do something to make that better?
§ Lord Elton
My Lords, I much regret that I shall have to ask the noble Baroness to be patient with me. I shall write to her because I do not have the detailed costing. I shall hope to see that my letter reaches her quicker than my last letter.
§ Lord Gridley
My Lords, I should like to ask the Minister a short question. Will these regulations be brought before the House and shall we have an opportunity of looking at them and possibly debating them?
§ Lord Elton
My Lords, I am sorry that I did not answer that question earlier. I should have done so. The answer is, "Yes". It is a negative procedure, but it is open to members of either House to pray against them. I would expect them before the summer recess.
§ Lord Molloy
My Lords, is the noble Lord aware that there are many people who will regret that he has demoted the parable of the Good Samaritan in favour of some of the ethics of the Merchant of Venice, and that squeezing this couple of ounces of flesh—£6 million —will not do credit either to the Government or to the nation? On the question of reciprocity, would the noble Lord be good enough to examine the situation where people who come to our nation somehow or other—and many try to learn and understand our ways to take them back to their own countries—will not be able to have any reciprocity in their countries? Also on the question of reciprocity, I think that the wider we can spread the principle on which the National Health Service is based throughout the world, rather than devoting millions to nuclear weapons, the quicker sanity will return.
In conclusion, I should like to ask the noble Lord whether it would be possible, rather than trying to squeeze £6 million out of sick people who might be coming to this country, to tighten up on the black economy of those very wealthy people who cheat the Exchequer to the tune of something between £7 billion and £9 billion a year? A little improvement on that vile situation would, as I have said, make it totally unnecessary to elevate the principles of Shylock in favour of the principles of the Good Samaritan.
§ Lord Elton
My Lords, I think that the noble Lord has expressed more sentiment than question. I find it difficult to say anything except that I have not met Shylock in the pages of the New Testament and cannot follow the analogy that he seeks to make. On the question of reciprocity, I have already said once and implied once that we are in favour of it where we can achieve it. Naturally there are countries which do not have a national health service equal to ours. Indeed, what the noble Lord has said makes it clear that no country has a national health service equal to ours, and, therefore, full reciprocity around the world cannot be achieved. And where it cannot be achieved, where people are not covered by reciprocity, they need to be covered, as I do not doubt the noble Lord himself is when he travels, with an insurance policy against unfortunate eventualities. I do not think that I 767 will follow the noble Lord, although every time we have exchanges across the Floor of the House he tempts me to follow him, into the area of the Budget even if I recognise the people he wishes me to pursue.
§ Lord Wedderburn of Charlton
My Lords, before the noble Lord finalises his thoughts as regards the matters he is going to investigate about overseas students, is he aware that it is a little alarming that there is not even a general figure to give as an estimate of the contribution to the £6 million which the charges on overseas students will provide? Secondly, is he aware that many people will hope that his right honourable friend will have had consultations with his right honourable friend in charge of higher education? Is he aware that a large number of overseas students are now a necessary condition for the survival of the university system in this country? Is he, therefore, able to give your Lordships, or able to promise to provide, the information which arose from those consultations as to the effect that these charges may have on the continuing availability of some of those higher education students? I ask that because, if I read in Hansard what I thought I heard—namely, the remark that overseas students could do what your Lordships could do; that is, insure against ill health for a year—is the Minister aware that he makes a very grave mistake, indeed, in believing that the large and welcome number of students who come to us from all over the world have that kind of financial affluence?
§ Lord Elton
My Lords, on the first point, it was not my intention to say that a costing did not exist. It was my intention to say that I regretted that I did not have it at my finger tips. I shall certainly give the noble Lord a copy of the letter which I send to the noble Baroness. The noble Lord is not alone in valuing overseas students at out universities. But the figures which he next asked me to reveal to him and their effects, were those for the changes in charges for tuition of overseas students, and that is the subject of a different question.
As to the matter of insurance, I can only say to the noble Lord that the need to provide for the unexpected is no less for the student than it is for anybody else. I am sure that the noble Lord will be the first to admit that it is a fairly costly business to come to this country for a course or to go to any other country for a course for two or three years, and this will not be a very considerable amount to take into the total expenditure. I do not wish to sound uncharitable to these people, but we live in the real world and I think that the Government, by reducing the qualification from three years to one year, have done something which the noble Lord might acknowledge.
Lord Wallace of Coslany
My Lords, I should like to take up one point with the noble Lord. I asked him what evidence the Government had of abuse. He replied that the evidence lies in the mail bags of Members of another place. I have been a Member of another place and so has the noble Lord, Lord Boyd-Carpenter, and many others. We all know about the abusive and semi-charging letters that arrive as regards which no evidence can be produced. It is sheer 768 hearsay evidence and, on the basis of the noble Lord's answer, obviously the Government have no evidence whatever, except on hearsay, and that is no evidence.
§ Lord Elton
My Lords, if the clock is right, we have spent 28 minutes on this. Perhaps I may just reply to that point. If, in fact, it proves that there has been no abuse, of course there will be no gains. if there is a gain of £6 million, then there has been an abuse. We believe that there has been £6 million-worth net of abuse, and that it is worth recovering.