Before I begin, I remind Members that they are expected to wear face coverings. Given the recent outbreak in Parliament, I expect to see everybody wearing one if they are not speaking. For those who do not have face coverings, I will ask the Doorkeepers whether they can source some spare masks. I remind Members that they are asked by the House to have a covid lateral flow test twice a week if coming on to the parliamentary estate. That can be done either at the testing centre in the House or at home. Please also give each other and members of staff space when seated and when entering and leaving the room. I assure the right hon. Member moving the motion that he will have his full 30 minutes. For those watching outside, we are somewhat delayed because of two votes in the House.
That this House has considered adult dependent relative visas.
It is a pleasure to serve under your chairmanship, Ms Bardell. I want to talk about an important topic that deserves more attention than it has had, and I want to urge the Minister to change the current hostile environment policy on adult dependent relative visas, which is undermining the national health service. The immigration system should treat overseas nationals working in the UK and their families abroad more fairly than it does at the moment. I want to focus particularly on the impact on people working in the NHS.
Nine years ago, in 2012, the Government changed the immigration rules to establish their hostile environment policy. Under one of the changes, elderly parents or grandparents of British citizens are permitted to join them in the UK only if they can demonstrate that they require a level of long-term personal care that their home country cannot provide. Before 2012, a dependent relative needed to show only that they were living alone
“in the most exceptional compassionate circumstances”.
Now, the rules state that doctors are prohibited from bringing their elderly relatives to the UK from overseas unless they meet a very strict set of conditions. The problematic rules are set out in paragraphs E-ECDR.2.4 and 2.5, and I will read them. Paragraph E-ECDR.2.4 states:
“The applicant or, if the applicant and their partner are the sponsor’s parents or grandparents, the applicant’s partner, must as a result of age, illness or disability require long-term personal care to perform everyday tasks.”
Paragraph E-ECDR.2.5 states:
“The applicant or, if the applicant and their partner are the sponsor’s parents or grandparents, the applicant’s partner, must be unable, even with the practical and financial help of the sponsor, to obtain the required level of care in the country where they are living, because (a) it is not available and there is no person in that country who can reasonably provide it; or (b) it is not affordable.”
I thank the right hon. Gentleman for raising such an important issue. His account from the doctor echoes that of a constituent of mine, a British national of Indian birth. She faces the same very difficult personal dilemma of having to consider, on the one hand, her patients and her service to the local NHS and, on the other hand, her parents in India. Does the right hon. Gentleman agree that when we discuss this difficult issue, we should bear in mind not only the potential impact on the NHS, but also the tragic personal stories and the trauma that it inflicts?
The hon. Gentleman is absolutely right. We are putting these dedicated public servants in an impossible position. I received an email yesterday referring to
“yet another consultant who has left the NHS (to live in Oman so that his mother could be with the family again).”
Six thousand doctors left the NHS to go overseas in the five years from 2015 to 2020. We do not know the reasons why they all went, but a significant number went for this reason.
The Chair of the Health and Social Care Committee, the right hon. Member for South West Surrey (Jeremy Hunt)—a former Secretary of State, of course—pointed out to the Prime Minister at Prime Minister’s questions today that
“there are now severe shortages in nearly every specialty.”
The policy we are debating this afternoon is part of the problem. We should be bending over backwards to keep doctors here. Instead, we are forcing them to leave the country. Many doctors feel very strongly, as the hon. Member for Ceredigion (Ben Lake) has just reminded the House, that they are being denied a family life. The emotional toll increases the risk of burnout.
In August this year, the British Association of Physicians of Indian Origin and the Association of Pakistani Physicians of Northern Europe carried out a survey of nearly 1,000 doctors in the UK, and 90% reported feelings of anxiety, stress and helplessness because of this issue. Is that really how the UK should treat doctors who have risked their lives to care for us throughout the pandemic?
The rules also have a severe impact on children in the families affected, not least through making it very difficult for them to have a relationship with grandparents. Equally, the Joint Council for the Welfare of Immigrants sampled a group of professionals in the UK. Of the 121 children affected, 20% came from families living in lower-income households, more likely single-earner households. It points out that having a grandparent who can help with childcare will enable parents to work in cases where childcare costs would rule that out.
Mr Khalid Mahmood (Birmingham, Perry Barr) (Lab)
I thank my right hon. Friend, who has done terrifically well to secure this very urgent debate. Coming from Birmingham, I know both the associations he referred to. To train a junior doctor costs about £230,000 and to train a GP or consultant costs about £500,000. Every time we lose one of those consultants or GPs, or even a junior doctor, it is a huge cost to us. Should the Government not understand when they are looking at value for money that these people are well paid and able to support the parents they bring over, and will contribute towards the health insurance that they have already agreed? This would give them peace of mind. They are hugely stressed at the moment and most are still thinking of leaving at a time when we need their expertise.
My hon. Friend is absolutely right. Having invested so much in their training, we need to keep those experts here, not force them to leave the country. There are more than 96,000 non-UK graduates on the General Medical Council register. The evidence of the potential loss to the NHS if these restrictions stay in place is enormous. We simply cannot afford that loss. The investment made in their training is a very important point; I am grateful to my hon. Friend for raising it.
This is a real threat, not a theoretical worry. The Association of Pakistani Physicians of Northern Europe said that
“in many cases, highly trained and competent”
members of staff are leaving the UK to return to their home country or go somewhere else where the rules are more accommodating in order to care for their elderly family members.
Of course, these rules will apply to EU citizens arriving to live in the UK post Brexit. They will deter skilled doctors from European countries from working here, as they are forced to opt instead for countries with a less hostile and more accommodating policy. I remind the House that adult dependent relative entry clearance applications to the UK are among the most expensive type of visas that there are. The cost of a visa application for an adult who requires care from their relative here is £3,250. The Government say these rules are to avoid burdening the NHS; I wonder whether the Minister can put a figure on the cost of a more accommodating policy. What is the estimate that we are talking about? What will be the cost of losing all these highly trained staff who are forced to leave to fulfil their family responsibilities?
The British Medical Association represents and negotiates on behalf of all doctors and medical students in the UK. In January, together with other leading medical bodies, it wrote to the Home Secretary asking her to remove this restrictive adult dependant rule for doctors. Soon after its letter, I wrote to the then Immigration Minister asking him to meet to discuss the issue. He declined my request to meet and simply told me,
It is a pleasure to serve under your chairmanship, Ms Bardell. I thank the right hon. Member for East Ham (Stephen Timms) for securing this debate. I also thank the other Members who contributed. I recognise the strength of feeling on the topic, as the right hon. Gentleman so eloquently articulated. I will respond to his points as best I can in the time I have, but it will be helpful if I set out some background on adult dependent relative visas.
The family immigration rules were reformed in July 2012 to ease the burden on the taxpayer, promote integration and tackle abuse, thereby ensuring family migration to the UK is fair to migrants and the wider community. Costs associated with cases under the route for adult dependent relatives can be significant. The Department of Health and Social Care has estimated that a person living until the age of 85 costs the NHS on average about £150,000 in their lifetime, with more than 50% of that cost arising from the age of 65 onwards. It is important to note that this figure does not take account of any social care costs met by local authorities.
Under the rules, adult dependants must demonstrate that they require, as a result of age, illness or disability, a level of long-term personal care that could be provided only in the UK by their sponsor here, and without recourse to public funds. They must apply from overseas and not while in the UK as a visitor. The rules in place before July 2012 in essence provided an expectation of settlement in the UK for a parent or grandparent aged 65 or over where they were financially dependent on their UK sponsor, subject to the provision by the sponsor of a five-year undertaking that they could maintain and accommodate the adult dependent relative without access to public funds. They also enabled a parent or grandparent under the age of 65 and other adult dependent relatives of any age to apply to settle permanently in the UK in the most exceptional compassionate circumstances, as the right hon. Gentleman said. The old rules allowed an application to be made in the UK, including while here as a visitor, as well as overseas.
Mr Mahmood
Does the Minister understand that this is not just a question of finances and money? This is an issue of relationships, of parents, children and grandchildren, and of building and understanding a family. We can support someone on their own abroad, but we cannot have that family linkage growing.
Yes, I fully understand the hon. Gentleman’s point, but the Government’s duty is to formulate rules that are fair to the British taxpayer and the NHS, and that ensure a fair system. I will come on to the specific issues about the health service to which the right hon. Member for East Ham alluded, but it is vital that our immigration policies do not place an unfair burden on the taxpayer.
We want to ensure that people here legally are welcomed and celebrated—which we do in this country—as part of a fair and sustainable immigration system. All family migration to the UK, including that of adult dependent relatives, must be on a properly sustainable basis that is fair to both migrants and the wider community.
Our position on adult dependent relatives remains that we have rules in place to support those who are most in need, but we are clear that the rules cannot provide a route for every parent to join their adult child in the UK and to settle here. It is simply not sustainable for the economy or the health service for there to be a routine expectation of settlement in the UK for parents and grandparents aged 65 or over. Therefore, only those who require long-term care that cannot be delivered in the country in which they live should be eligible to settle here.
We fully understand that such cases provoke strong feelings, as Members have articulated, and they can result in difficult choices for individuals, but it is essential that the rules are fair and balanced for the taxpayer, given the significant NHS and social care cost that can arise when those adult dependent relatives settle in the UK. Failure to maintain that balance puts the legitimacy of the entire system at risk.
I now turn to the issue of the NHS. Of course, we are hugely grateful for the vital contributions of all NHS staff, in particular during the pandemic. The Government have no intention whatever of punishing that group. By contrast, we have introduced a range of unprecedented measures to ensure that the health and care sector is supported fully. However, it is only fair that I address the points that have been made.
Just to elaborate and perhaps add to the considerations, there is of course an impact on the family, but there is also an impact on the community. In many rural areas, such as mine, if we lose a solitary GP, who has to go back, we will not have a GP practice for a very large area, so there is that wider impact too. We should bear in mind that even though it may be an individual example, it has quite a widespread impact.
Of course, I recognise the impacts of the issues highlighted by the hon. Gentleman. On the point made by the right hon. Member for East Ham, that we have not considered other ways to avoid the burden on the NHS and local authorities, making comparisons with other countries and their systems, I advise him that we did consider other ways. The Home Office published a review of the adult dependent relatives rules in December 2016. As I said, we continue to keep this under review. The report is published on gov.uk, so I encourage him to look at that.
As part of the review, specific considerations were given to alternative methods of achieving the main aim, which is reducing the burden on the taxpayer and NHS costs. Those alternatives were mandatory medical and care insurance, amendments to the immigration health surcharge and a bond scheme, requiring up-front payment, which would be offset against the cost of any later NHS care. Particular consideration was given to how far each of those would achieve the policy intention, be feasible to administer, and continue to allow an adult dependent relative, with significant long-term personal care needs that could not be met in their home country, to join their relative.
Those options were considered to place a potentially unreasonable administrative burden on the NHS, while also raising significant concerns over affordability and discrimination. For example, mandatory private healthcare insurance was considered likely to be prohibitively expensive, especially if it was to cover NHS emergency treatment and/or social care and residential care. It would also benefit only those applicants whose sponsor had substantial means. Those without a close relative with such means would be excluded from the UK, even if they required long-term personal care that could only be provided by their relative here. There is also no guarantee that insurance taken at the date of application would not be later cancelled or not renewed, including in circumstances outside that person’s control, such as a significant deterioration in their health or a change in the financial circumstances of their sponsor making the insurance unavailable or the premiums unaffordable.
The Minister makes the point that there is no evidence of doctors leaving the UK for this reason. We do know that 6,000 doctors left to go overseas in the five years between 2015 to 2020. She is right that we do not know the reason why they all left, but it is clear that at least hundreds went for this reason, and possibly more of those 6,000. Is she not concerned about that loss of skilled, committed doctors from the health service, at a time when—as the Chair of the Health and Social Care Committee, the right hon. Member for South West Surrey, pointed out at lunchtime today—there is a shortage in nearly every speciality?
I thank the right hon. Gentleman for his point. He is right to ask the question. As I said earlier, we do not have verified evidence of those numbers, and nor do we have specific evidence pointing to this specific reason. There may be a number of reasons why people choose to leave and work in another country. Moreover, I point to the evidence in front of us about the people who are choosing to take up those skilled visas to come to this country, so these rules are clearly not a deterrent. I refer to my earlier remarks about the policy intention behind introducing these changes to the rules, which is to make sure that only those people who genuinely need to come here are covered by these rules, and therefore would be able to come here under the system that we have.
In conclusion, I recognise that this is an emotive subject, and I pay tribute to the right hon. Member for East Ham for the way in which he has articulated it. Of course, I and the Government want to support the NHS. We keep our policies under review, as I have said, and we have given considerable care and consideration to the factors that he has mentioned.
The Minister is being very generous with her time. She has made much of the cost issue; I think she indicated that for somebody elderly arriving in the UK, we would expect health and care costs of something like £175,000, but a GP has had £500,000 invested in them. I wonder whether an assessment has been made somewhere of the value for taxpayers—the straightforward financial cost—of forcing somebody who is highly trained out of the country, versus the cost of care for their elderly relative.
I can reassure the right hon. Gentleman that the costs have been considered in the round, including the costs he refers to and others. In fact, those figures I quoted at the beginning of the remarks did not include care costs, which I am sure he will agree are significantly higher than the other figures I have referred to, which are purely for treatment and costs.
Motion lapsed (Standing Order No. 10(6)).
In practice, those conditions are extremely hard to meet. Home Office data shows that in the four years from 2017 to 2020 inclusive, 908 visa applications were made under the adult dependant rule. Only 35 were approved at the first attempt. Over 96% of them were refused. Some were subsequently granted after the difficulty and expense of an appeal. In 2017, I understand the Home Office did not issue a single adult dependent relative visa. Before the rule changes, thousands were approved.
What is the justification for the change? Ministers have argued that the rules are to stop adult dependent relatives from entering the UK and burdening taxpayers. Other ways to avoid any burden on the NHS and local authorities do not appear to have been considered. The existing immigration health surcharge could be incorporated into adult dependent relative applications—Canada, Australia and New Zealand have that sort of model in their schemes for elderly migration—or applicants could be required to have private medical insurance. Instead, we have made it virtually impossible for elderly relatives to come.
Over the past two years, we have all been reminded just how important the national health service is. I know I speak for all of us when I say how grateful we are for the extraordinary efforts of doctors, nurses and other NHS staff to protect and care for all of us throughout the pandemic. They should be rewarded for their hard work and dedication. Instead, many are being punished with these hostile immigration policies.
One doctor, a British national based in Birmingham, told me about the impact on him. He came from India to train as a GP in 2004. The UK is now his home. He studied here, he is working here, he is bringing up his children here. Sadly, he lost his father to covid in India earlier this year. Now, his 70-year-old mother wants to join her son and his family in the UK, but she is not allowed to do so, because of these rules. He tells me that
“no matter how much I earn and pay in taxes, my inability to look after my mother makes me feel incomplete and unfulfilled.”
He also feels his children are being denied a proper relationship with their grandmother. He says that
“my children should not be penalised for a decision I took 17 years back to move to the UK.”
The Government have said that the rules on adult dependent relatives are in place to protect the NHS. They are actually undermining it. Medical professionals have busy, stressful lives, even more so in the pandemic. Those with vulnerable relatives abroad often have to take leave, sometimes extended leave, and travel overseas often to arrange care for their elderly parents, at a time when the NHS needs them here, and we need them here more than ever. Some doctors have been forced to leave the UK altogether. In the survey I referenced a moment ago, eight in 10 respondents were looking at leaving due to these rules.
“those most in need of care remain the most likely to qualify.”
The problem is that enormous numbers are not able to come. According to the Home Office, just 70 adult dependent relative visas were issued in 2020. The Government need, at least, to review their application process to determine just why so few applicants succeed. I am certain the Minister will have received representations from the Health Secretary about this issue, and I hope they will undertake a review.
The BMA has consistently raised concerns about the potential impact on patient care and on the wider NHS if doctors have to move because of these rules. Ministers do not seem to take much notice of the urgent concerns of those working on the frontline of our health service, but it is time to start taking notice before serious harm is inflicted on the NHS. Doctors must not be kept waiting any longer. There is no justification for forcing committed, dedicated NHS doctors to choose between their work and their home in the UK, and their deeply felt duty to their elderly parents to support and care for them in difficulty and old age.
Will the Minister commit today to review this unfair policy? Why have so few applicants been successful in the past nine years? Why are Ministers weakening the NHS in order to prevent elderly relatives from joining their key worker families here in the UK?
The current rules for adult dependent relatives seek to ensure that only those who need to be physically close to and cared for by a close relative in the UK are able to settle here. Those who do not have such care needs can be supported financially in the country in which they live by their relative in the UK. Those in most need of care remain those most likely to qualify, compared with those who have a preference to come to live in the UK with a relative here. The lawfulness of the rules was upheld by the Court of Appeal in May 2017.
The impact of medical professionals potentially leaving the NHS was an issue that was raised five years ago and considered as part of the Home Office review of the adult dependent relative rules published in December 2016. That report considered the number of NHS staff who support adult dependent relatives overseas. It is likely to be a small proportion of the total population of professionally qualified clinical staff.
Furthermore, there is no evidence to show that significant numbers of medical professionals have left or been deterred from applying to work in the UK since the revised rules were implemented. It was concluded that, while some who might sponsor someone to come to the UK might choose to leave as a result of the revised rules, including some in skilled employment, the impact remains proportionate to the policy aim.
The latest figures show a 19% increase in skilled worker visas in the year ending June 2021, and that the majority of that increase was due to the new health and care worker visa, which saw 45,722 grants, accounting for 44% of the total skilled worker visas granted. In fact, such was the demand of overseas doctors and nurses wanting to work in the UK, in 2018 the Government lifted the cap on doctors and nurses. The Health Secretary at the time said:
“Overseas staff have been a vital part of our NHS since its creation 70 years ago. Today’s news sends a clear message to nurses and doctors from around the world that the NHS welcomes and values their skills and dedication.”
As I said, there is no evidence that significant numbers of professionals have been deterred from applying to work in the UK since the new adult dependent relative rules were implemented, and nor is there evidence to show that professionals have left the UK.
The NHS has made significant savings since the rules were introduced. The 2016 report notes that once assumptions were taken into account, the figures suggested potential NHS savings of around £249 million over 10 years. This policy will be kept under review. We are of course sympathetic about the impacts on individuals and families, but the policy must apply fairly across our society. It would not be right to provide a more generous approach for healthcare professionals than for other groups.
Any alternative scheme requiring an up-front payment of many thousands of pounds would, by definition, exclude those cases unable to pay it, regardless of the level of their personal care needs. Similarly, in the light of the estimates I mentioned earlier—that a person aged 65 to 74 costs the NHS £2,287 per year—such a scheme for adult dependents would likely need to be set at significantly more than its current level. That is why it was concluded that the revised rules were set at the right level to provide immediate settled status in the UK and free access to the NHS to those relatives whose care needs could not be met in their home country, while protecting the NHS and the tax burden.