[Relevant documents: Third Report of the Health and Social Care Committee, Workforce: recruitment, training and retention in health and social care, HC 115; Summary of public engagement by the Petitions Committee on immigration fees for healthcare workers, reported to the House on 24 January 2023, HC 73.]
That this House has considered e-petition 604472, relating to immigration fees for healthcare workers.
It is an honour to serve under your chairship, Mr Sharma. It is a privilege to introduce this petition and give voice to the thousands of healthcare workers for whom this discussion is an opportunity to raise an issue that has not only a significant detrimental impact on their lives and careers, but a huge impact on the availability and quality of healthcare in the United Kingdom. Although the petition is focused on changes that are within the remit of the Home Office, to understand the reasons behind it and why this is such an important issues for the petitioner, Mictin, and tens of thousands of his NHS colleagues, we have to understand that the most British of institutions, the national health service, would collapse without staff who are not British nationals.
According to the House of Commons Library, about 16.5% of NHS England staff are not British nationals. Of those 220,000 staff, more than half—just under 120,000—are from outside the European Union. Let me break that down a bit. Figures from the General Medical Council tell us that in 2021, more than half of new doctors working in the NHS came from overseas. There are 146,664 internationally trained professionals on the Nursing and Midwifery Council register—almost one in five of the nursing workforce. The Royal College of Radiologists’ recent workforce census found that in England, 27% of the clinical radiology consultant workforce and 20% of clinical oncology consultant workforce gained their primary medical degree in non-European economic area countries.
The list goes on across roles and specialisms, and that is before we even get to the healthcare workers who work in social care and provide support as home carers or in nursing homes.
Although it is welcome that the scheme has been extended to care workers under a 12-month trial, they are some of the lowest paid in the sector. The at-home care area of healthcare is facing some of the biggest difficulties of any across the UK. Does the hon. Lady share my concern that the costs are completely unaffordable for care workers?
I agree with the hon. Lady. The scheme has been extended by 12 months, but care workers are the lowest paid, and these are some of the biggest costs.
The numbers tell only part of the story. Although it is essential that we know the facts and figures, I would like hon. Members to think about what those numbers translate to for patients. Those clinical oncologists are helping to reduce the backlog of patients awaiting checks, scans and treatment, and are delivering life-saving care to cancer patients. Those midwives are guiding mothers through pregnancy and helping to bring their children into the world. Those doctors and nurses gave so much during the covid pandemic, worked all hours, did not see their own families, saved lives and comforted those who could not be with their families in their final hours.
During the pandemic, I was involved with GMB’s campaign for NHS cleaners and carers to be granted indefinite leave to remain after the sacrifices they made. Does my hon. Friend agree that we need to lower the cost of indefinite leave to remain and show the same level of gratitude to health workers who had to work during one of the most severe crises that our NHS has experienced?
It is true that these have been the most challenging of times, and indefinite leave to remain is one way of addressing that.
As we discuss the petition, I urge hon. Members to remember that when we talk about health and care workers, we are not talking in the abstract. We must remember the very real impact that Government decisions have on people’s health and wellbeing. There is little argument that workers from overseas are not essential to the running of our healthcare system. In fact, NHS trusts actively recruit from around the globe.
The health and care worker visa we are discussing was introduced to speed up processes to ensure that much-needed health and care staff could work in the United Kingdom. Despite broad agreement that there is obvious need in our overstretched health and care sector for overseas professionals, the current system is failing to retain these key workers. The expensive, drawn-out indefinite leave to remain process is pushing many key workers away, creating financial and bureaucratic barriers for those who wish to stay and to continue working in this country.
A greater number of healthcare workers settling in the UK would only benefit the health system. Not only does better access to ILR make the UK more attractive to the international workforce; better staff retention provides employers with greater long-term security for workforce planning, which I know at first hand is a key issue. Indefinite leave to remain allows for greater mobility between sectors and employers, as well as greater flexibility to deploy internationally recruited workers where need is greatest, rather than being hamstrung by restrictive visa requirements.
The financial barrier is high. The Migration Advisory Committee has highlighted the general high cost of these fees compared with other countries. The cost to apply for ILR sits at £2,404 per person. However, the latest visa and transparency fees data suggests that the estimated cost of an ILR application is just £491. In the context of a decade of pay erosion and the cost of living crisis, ILR fees may simply be unaffordable for many healthcare workers.
It is an honour to serve under your chairmanship, Mr Sharma, and a pleasure to speak on a topic that I suspect will have agreement from Members on all sides of the House, with the possible exception of the Minister; we cannot have everything, I suppose.
I thank the Petitions Committee for bringing forward the debate on such an important and timely topic. The issue is close to my heart; I declare an interest as my partner is a healthcare worker from the Philippines and is intrinsically involved in the system we are debating. The debate is also timely, as I have a ten-minute rule Bill on this very topic coming before the House in the next few weeks.
I have spoken on this topic several times in the past, both in Westminster Hall and the Chamber. Last year, I tabled an amendment to exempt NHS clinical workers from paying the fees associated with applying for indefinite leave to remain to the Nationality and Borders Bill. I discussed the amendment with the Minister at the time, the now Minister for Disabled People, Health and Work, the hon. Member for Corby (Tom Pursglove) and his hon. Friend, the Member for Torbay (Kevin Foster), who had responsibilities in that area. I was told that my amendment, which was unusual in this House as having signatures and support from Members from six different parties, was not acceptable to the Government because, “We couldn’t go making special cases out of certain groups of people.”
Shortly afterwards, as the Bill was making its way through the House of Lords, the Government announced that armed forces veterans would be exempt from paying fees for ILR applications, which I thought was interesting given that NHS workers were not worthy of special consideration just a couple of months before. The Home Secretary at the time, the right hon. Member for Witham (Priti Patel), said:
“Waiving the visa fee for those Commonwealth veterans and Gurkhas with six years’ service who want to settle here is a suitable way of acknowledging their personal contribution and service to our nation.”
Some 28% of respondents to the Petitions Committee’s survey on this issue said that they had delayed applying for indefinite leave to remain in the UK due to the high costs. If the public sentiment is that fees should be lowered to resolve the crisis, does the hon. Gentleman share my concern at the Government’s reluctance to do so?
Completely; this is something I have debated. As I say, my partner is from the Philippines and, because of that, I now have a big extended family and friends who are Filipino and are overseas. They are all in the same boat. As I will explain in a moment, the type of things they have to go through, and the debts they get into, are ridiculous. I completely agree with the hon. Lady.
The NHS has played a vital role. Although the whole NHS deserves our thanks and gratitude, they should in particular go to our NHS workers who have come from overseas. They have travelled huge distances to be here, often separated from their families and putting their own lives at risk to help and save our lives—citizens from a different country to their own. Regardless of their or our citizenship, the duty to care and contribute to the wellbeing of others always comes first with them. It is amazing, and we as a society should highly commend it.
I welcome the number of steps the Government have already taken for foreign NHS workers, including the health and care worker visa and exemption from the immigration health surcharge, but we need to do more than that. These people want to make the UK their home. They put down roots—we have a duty to put in place a framework to allow them to do that without thousands of pounds in costs just to stay in a country to which they have already contributed so much.
So many of my constituents have contacted me to say that these fees are absolutely too expensive for those in the healthcare profession. Why does the hon. Gentleman think the Government have kept the fees so high and have not lowered them?
The hon. Lady imputes to me knowledge that is far above my pay grade, but I am sure the Minister will be delighted to answer her when he takes to his feet later. I have no clue, but it is ludicrous. As the hon. Member for Gower (Tonia Antoniazzi) said earlier, the cost is £420-odd to process these things. I will come to the fees in a minute, but there cannot be any justification for that cost. Going back 15 years, it was a fraction of what it is now; the fees have increased at an exponential rate over the past five or six years. I am sure that the Minister can enlighten us on that later; I look forward to the answer.
Of course, it is worse in the part of the world of the hon. Member for Lewisham East (Janet Daby). The cost of living in my constituency in north Wales is significantly less than it is down in the London boroughs. The extra pressures and the compounding of that problem are much worse: I completely agree.
As we have mentioned, fees for ILR are over £2,400. Citizenship, 12 months later if so desired, costs another £1,800 or so, plus a few £100 for biometrics, English language tests and all the other supplementary things that have to be done. The naturalisation process costs more than £4,000. That is one of the most expensive in the world. The process of becoming a citizen for NHS workers is costly and challenging.
The process includes the ridiculous “Life in the UK” test. I am not sure whether anyone is familiar with that test: it is a wonderful thing. It asks questions such as, “Which palace was a cast-iron and plate glass building originally erected in Hyde Park to house the Great Expedition of 1851?”, “In which century did the first Christian communities appear in Britain?” and, “Which two British film actors have recently won Oscars?” Quite how anyone can be expected to properly integrate into British society without that pivotal knowledge, I have no clue, but there we are. They have to pass that sensible test.
It is a pleasure to serve under your chairmanship, Mr Sharma. I congratulate my hon. Friend the Member for Gower (Tonia Antoniazzi) on the way she laid out the debate.
Everybody should realise that the NHS has always relied on staff from all over the world. It literally would not exist without the contribution of doctors, nurses and NHS staff from outside the UK, starting with the Windrush generation, who were also treated terribly by this Government’s Home Office.
The NHS is currently in a dire state, and the industrial action being taken by care workers is a clear example of that. At the heart of the crisis facing our health service is the struggle to recruit and retain healthcare staff, and the cost of living makes that even worse. Some healthcare workers who are paid less are having to use food banks, and in-work poverty is even greater for migrant workers due to the cost of living.
Reducing the cost of visa applications for overseas healthcare workers seeking indefinite leave to remain is not only just and fair, particularly for their families, but it would address the recruitment and retention crisis in the NHS by encouraging overseas workers to remain in the profession. It lacks humanity and economic sense to leave those key workers living in perpetual uncertainty about whether they can remain in the UK. They have to pay extortionate fees to do so, but they are working and contributing to the economy of this country.
The Government have repeatedly argued—the hon. Member for Delyn (Rob Roberts) said this too—that not giving special treatment to NHS workers is about creating a level immigration system, but our immigration system has never been equal and the people making applications have never been treated the same. That is reinforced by the Government’s points-based system. A millionaire who wants permanent residency in the UK can move things along a lot faster just by putting millions in a bank account in the UK. There is a shortage occupation list. There are thresholds for being able to bring family members over. We differentiate between people who have ILR and certain visas on the basis of whether children they have here are automatically granted British citizenship. We have never treated everybody equally, and on top of that we charge some the immigration health surcharge—even NHS workers.
My hon. Friend is making an excellent speech. Does she agree that the Government are behaving in a rather ironic way by encouraging people from skilled professions and backgrounds to come to our country to work, but then making it very difficult for them to settle?
My hon. Friend is absolutely right. Why are we making overtures to people in other countries and waiting for them to come here, only to treat them with complete contempt and disrespect and leave them in really serious situations where they are trying to support their families, and also making it difficult for their families to remain here? We all understand how important it is to have our families around us, but as we have already heard, some people have to leave their families behind and then face unreasonable barriers to bringing them into the country.
These people are doing so much for us, coming to our country to serve us as NHS workers at all levels: doctors, nurses, cleaners and porters, and let us not forget our social care workers. We need to make sure that we are treating them with the respect they deserve, no matter where they happen to have been born.
It is good to see you in the Chair, Mr Sharma, and it is a pleasure to take part in this debate. I thank the hon. Member for Gower (Tonia Antoniazzi) for introducing the subject so comprehensively and eloquently, and I also thank her and her colleagues on the Petitions Committee for bringing it before us for debate in Westminster Hall. The Committee also did a great job in carrying out the survey that has helped inform some of the contributions that have already been made, and which I will come to shortly. I thank colleagues for those contributions, which have all been very powerful.
As colleagues have said, the starting point of this debate must be praising the international NHS staff. We have heard about the extraordinary contribution of those overseas nationals who come to join with UK nationals in order to keep our national health services “brilliant”—to use the word that the petitioners have used—and we have heard facts and figures about how significant the contribution of those overseas nationals is. Around one in six NHS staff members in England is non-British, and if I have understood the figures correctly, it is pushing on one in three doctors and one in four nurses. Overall, there are over 200,000 overseas NHS staff, coming from over 200 countries. GP practices are no different: we had a very constructive debate in Westminster Hall a couple of months back about some of the problems with keeping international medical graduates here as GPs, and the Minister took some points away from that debate. It will be interesting to see whether there has been any progress in the work being done to encourage more of those graduates to stay, because there is a gap in how the visa process works in relation to people wanting to stay on as GPs.
In particular, we should all recognise the extraordinary role that overseas workers in our NHS played during the pandemic, and indeed the sacrifices they made in protecting us from covid and treating those who suffered from it. I think I am right in saying that overseas nationals were disproportionately represented in the number of health workers who lost their lives during the pandemic.
Although health policy is devolved, visa and immigration policy is not, which means that the decisions of Ministers here in Westminster are having a direct impact on the devolved Administrations’ ability to build resilience in healthcare staffing and to resolve the crisis. Does my hon. Friend know how Ministers have sought to engage with the Scottish Government on this issue?
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In the online survey of petitioners run by the Petitions Committee, respondents said they found it difficult to save up for indefinite leave to remain fees because of low salaries and a high cost of living, especially where they would need to pay ILR fees for multiple family members. One nurse who answered the survey said,
“I work as a deputy sister. I’m a single mum and my 2 kids have recently joined me in the UK. I cannot afford the ILR fees for me and my 2 children. With the salary of nurses and the cost of living here, a single mum like myself cannot afford it.”
A medical practitioner who responded said,
“As with current pay and cost of living crisis, it’s impossible to save this much. I am forced to buy used and second hand items only. I buy the cheapest groceries. Try and only use heating when absolutely required…I am forced to work weekends to save. I am hardly spending time with family. My mental health is affected. It feels like I’m a slave forced to labor…I don’t understand why the government would keep a fee that would force workers to leave NHS and UK…I survived through all waves of covid and staffing pressure. Had multiple illnesses because of my work. I don’t think I’ll survive this one. I believe these fees will break me.”
The fee is not the only cost; it is in addition to other substantial visa fees paid in the years prior to eligibility.
Workers without ILR are also subject to the no recourse to public funds policy. The cost of living crisis brings into sharp focus the potential financial hardship that internationally educated workers who are unable to access public funds could face. Members of the Royal College of Nursing consistently report the negative impact that the policy has had on their lives and the lives of their families. The covid-19 pandemic has exacerbated the challenges that individuals with no recourse to public funds were already facing, with these families identified as being at high risk of living in insecure and crowded housing.
Making the ILR process more accessible would bring significant benefits to individual workers who report that their mental health is suffering as a result of the financial pressures they are facing to try to meet the costs of ILR. A healthcare assistant who responded to the Committee survey said
“With the ever rising cost of living, [saving for ILR] becomes mentally draining for an already overwhelmed health worker. Reducing the cost shows the government care about the wellbeing of health workers and promotes work life balance because families have to work odd hours to meet up with the fees.”
The RCN also reports that nurses sponsored under the health and care visa often have difficulty reducing their working hours because of the minimum salary threshold —£20,480 per annum—that is applied to their visa. Given that there is no provision for that to be applied pro rata for part-time staff, the RCN understands that the policy often conflicts with nurses’ caring responsibilities.
Better settlement pathways can help to tackle abusive labour practices, reducing the ability of predatory employers to use immigration status to tie staff into exploitative situations. This is particularly relevant in the care sector, where the director of labour market enforcement has identified workers as being at high risk of exploitation. The RCN is aware from member reports that employers will, on occasion, use threats of deportation to coerce staff into paying extortionate repayment fees should they choose to leave employment early.
The current policy means that the UK is already losing overseas healthcare staff to other countries.
“I couldn’t raise the money [for ILR] for the last 2 years to apply, so I’ve gotten a better salary offer in New Zealand…so I’ll be leaving the UK.”
Those are the words of one nurse who responded to the petition. A trainee doctor told us:
“With paying for exams and training, I don’t have enough money to apply for an ILR, which makes me think to leave the UK and work in Australia after I qualify as a GP.”
The petition is not simply asking for a reduced fee for those health and care workers seeking ILR; it is asking for a joined-up approach from Government, and for a better system that will improve the lives of those using it and enable us to provide a strong and sustainable health sector.
Earlier, I told hon. Members that it was essential to remember that behind the figures, statistics and costings, we are talking about people, so I will finish by telling hon. Members about the person who kicked this all off—the petitioner, Mictin, who is here today with his family—and why he started the petition. Mictin was actively recruited to the NHS from India, as NHS trusts use local agents to recruit for them. Of the 23 other overseas workers who started with him when he came to Leicester, only six are still working in the trust. The costs of pursuing ILR were too much for many of them and some have found new work abroad—skilled workers who have left the United Kingdom because we have made it too difficult to stay.
We ask people to make the choice to come to the United Kingdom, but we have not ensured that we have a system that makes that choice an easy one. We force difficult choices on the workers we need. Mictin and his wife have made the choice to stay, but we have not made it easy for them. Mictin’s parents-in-law have never seen their grandchild, because the cost of taking him to India would mean greater delays in applying to ILR. Mictin started the petition because he knows he is not the only one making these difficult choices. While our health sector desperately needs more Mictins, we have to ask why we are making the choice to stay so difficult.
Taking nothing away from veterans who have put their lives on the line in the service of this country and the Commonwealth, I think one would be hard pressed to find many members of the public who did not believe NHS clinical staff should be worthy of the same consideration.
In similar debates, I have told the tale of Carrie, a real-life case using a different name. She moved to the UK in 2016, leaving her husband and four-year-old child back home in south Asia. It took another year for her husband and daughter to join her because of the cost involved in a dependant visa. They could be together again as a family only once she took out a loan, which she paid for over the next three years. She had to get another loan three years later because she was due for a renewal of that visa, adding a load more fees.
In 2021, Carrie was entitled to apply for ILR. With loans still ongoing from previous renewals, what choice did she have? What could she do? She had to take another loan—even bigger than before—just to have the right to occupy a space in this country and call it home. She pays her taxes every month; she has done for years. She works in an intensive care unit. She has spent all her working life in this country saving lives, especially during the pandemic. As I have said before, she should not be in debt. We should be in her debt.
It is our duty in this place to create a new route for citizenship for NHS workers that will not leave them in debt, in poverty or—as the hon. Member for Gower said—in mental anguish with the constant worry of funding the next application. By reducing the costs associated with ILR and citizenship, and in time abolishing them completely, we can help to do just that.
I am proud that our NHS attracts global talent and recruits from around the world. Quite frankly, we would be—I was going to swear there—we would not be able to run it without them. We would be in difficulty. In 2021, over 160,000 NHS staff stated that they were of a non-British nationality, from over 200 different countries. That accounts for nearly 15% of all staff for whom a nationality is known. However, the current fees and process are a huge barrier to both future NHS workers, who are put off coming because they do not feel they will be able to stay long term, and to current NHS workers, who are unable to afford the final step to have the permanent residency that they have earned through service to our country.
Residency and citizenship should not be about cost. They should be about contribution and inclusion in our communities. NHS workers have perhaps given the biggest contribution of all by saving our lives and keeping us safe. If they are not citizens, they cannot be fully part of the communities in which they live and work, despite being such valued members. Without ILR, individuals face barriers to home ownership, as it is almost impossible to get a mortgage without it. It is difficult in the job market and higher education. There are barriers wherever we look. Reducing the fees, or even scrapping them entirely, would not only make residency and citizenship more achievable, but create a more diverse and, crucially, a more integrated society. People from other countries who have worked in our NHS during the pandemic and throughout their lives deserve to be able to call the UK their home, and actually feel like it is.
The pandemic has been horrendous, but it has had one benefit. It has highlighted what many of us already knew: our NHS workers, whether British or not, are the backbone of our health service and our country. Those who have come here to provide such incredible care should not be penalised for it, but the high application fees do just that. It is time to reduce, if not entirely abolish, the fees for ILR and citizenship for those who work in our NHS so that those who spend time helping and treating us can finally feel like they belong and are welcomed with open arms.
Several healthcare professionals from across the country, both from migrant backgrounds and not, support this petition. I will talk about what one of them said to me. It costs £2,400 for an ILR visa, but he is being asked to pay 10 times more for his family. That family of four is being asked to pay £12,000 just to have indefinite leave to remain. He said:
“NHS staff get recruited to work in terrible conditions. We can’t pay our bills, and then we’re charged thousands of pounds just to stay here and work. Given the terrible NHS staff shortages, this policy reaches next-level stupidity.”
I agree with that doctor. We cannot afford to lose doctors such as him, especially when other countries are taking steps to attract them. We have already heard about how some people are leaving us. Given the shortages of NHS staff in this country, we simply cannot afford that. We will tackle the chronic shortages only by treating all staff decently.
The Government have explained again that they are maintaining their hostile environment—I know they call it something else—to make the country less attractive to people who want to enter it illegally. Obviously, I take issue with the people they term “illegal”, but they are also making it hostile for people who, by their own definition, are legal. How does that make any sense? Those people have been asked to come here to support our services. We are not talking about people who are visitors, or who want to take from our country. We are talking about people who are saving people’s lives—who are working in our NHS daily, who saw us right through the pandemic. Those people have left their own countries to come and serve ours, and they are doing a fantastic job.
The next part of the equation is, of course, that the NHS continues to face unparalleled challenges, particularly in terms of vacancies. Despite the huge contribution of the overseas workforce, figures also show that massive vacancy rates remain. As of September, NHS England had a growing vacancy rate of just shy of 12% for registered nursing staff: full-time equivalent staff vacancies in NHS trusts in England increased from about 133,100 in June to 133,400 in the quarter to September 2022, which I think is a five-year high. Overall, the vacancy rate in the quarter to September 2022 was 9.7%—again, a five-year high.
The important point, putting aside all the numbers, is what those vacancy rates mean in practice. Last year, a RCN survey found that only a quarter of nursing shifts have the planned number of registered staff on duty, which means that three quarters of shifts are going ahead with a shortage of nurses. In the ideal world, even if some nursing staff had to call in sick, we would have enough nursing staff to cover for them, but even with the full complement on, we are still short-staffed—we spend £3 billion every year on agency staff.
It is absolutely valid to say that the answer has to be partly about improving training and recruitment locally and ensuring that we can rely on the domestic workforce much more in the longer term. However, as the Health and Social Care Committee recently pointed out, overseas workers are essential to the health and social care system in the short term and in medium to long term: any move to shift to more domestic supply is likely to take time. We will have to continue to rely on overseas nationals filling those jobs in the years ahead.