Letter Journal of the Royal Society of Medicine; 2014, Vol. 107(12) 466–467 DOI: 10.1177/0141076814555940
To submit a letter in response to a JRSM article, please visit http://jrsm.sagepub.com to find the article concerned, then click on the ‘Submit a comment’ link found in the Reader Responses section. Comments will automatically be submitted for consideration to be published in print.
We must recognise the actual and opportunity costs of treating immigrants in the NHS I am surprised by Steele et al.’s article decrying the health aspects of the Government’s Immigration Bill 2013–2014.1 The authors work in East London, as I do. They should therefore be well aware of the burden of infectious diseases associated with London’s immigrant populations, e.g. tuberculosis (TB), HIV and viral hepatitis. Treating these infections is costly. For example, treating Extensively Drug Resistant TB (XDR-TB), which occurs mostly in immigrants, is very expensive compared to drugsensitive TB.2 Some of the statistics quoted are questionable. The authors state that ‘immigrants account for 4.5% of the population of England’. However, the 2011 Census stated that 9.4% of the population of England are immigrants.3 Health tourism is a vague term. It refers both to wealthy foreigners availing themselves of UK private healthcare and to NHS healthcare provided to immigrants not entitled to free care. The former is beneficial to the UK, the latter is not. Like the authors, I am aware of the potential benefits of immigration. The NHS could not function without its foreign staff. However, unlike the authors (perhaps), I recognise the significant costs of treating immigrants. We must recognise the opportunity cost of expending limited NHS resources on those who are not entitled to it. Every pound spent on immigrants not entitled to free NHS care is a pound we cannot spend on Britons who are entitled to this care. As public servants, we have a responsibility to ensure that publicly funded resources are expended properly on those who are entitled to it. Finally, most NHS Trusts, including the authors’ local NHS Trust (Barts Health), have an overseas patient policy which requires staff to identify patients not entitled to free NHS care. These policies apply to all NHS Trust staff and for good reason. Declarations Competing interests: I work for Public Health England (PHE), an executive agency of the Department of Health. I am a civil servant
writing in support of this Government immigration policy; I do so of my own free will.
References 1. Steele S, Stuckler D, McKee M and Pollock A. The Immigration Bill: extending charging regimes and scapegoating the vulnerable will pose risks to public health. J R Soc Med 2014; 107: 132–133. 2. Pooran A, Pieterson E, Davids M, Theron G and Dheda K. What is the cost of diagnosis and management of drug resistant tuberculosis in South Africa? PLoS One 2013; 8: e54587. 3. Office for National Statistics. 2011 UK Census: Country of Birth, Local Authorities in England and Wales (Table KS204EW). London, UK: Office for National Statistics.
Gee Yen Shin Public Health England, Department of Infection, 3/F Pathology and Pharmacy Building, The Royal London Hospital, 80 Newark Street, London E1 2ES, UK Email: [email protected]
Authors’ response to Shin: We must recognise the actual and opportunity costs of treating immigrants in the NHS In our paper, we noted explicitly that the Government’s proposals are politically motivated, rather than practically. Hence, it is unsurprising that there are some, such as Gee Yen Shin, who take a different view about the UK’s responsibilities to migrants who come to this country. There is a considerable mythology that has grown up around the costs of illegal immigrants and abuse of services, which has been refuted.1 However, our article notably focused on the practical implications of this political decision, both for migrants and the public at large. Is Shin really suggesting that patients should go untreated because they are no longer entitled to ‘free care’? In the context of tuberculosis, it is useful to recall the epidemic that occurred in New York in the 1980s and 1990s, which included multidrug-resistant outbreaks, and that eventually cost more than US$1 billion to address.2 Such an epidemic in the UK would certainly be undesirable, both in terms of its
! The Royal Society of Medicine 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav Downloaded from jrs.sagepub.com by guest on August 13, 2015
Shin
467
human and economic costs. Indeed, while small amounts of savings for the NHS might appear justifiable in the short term, in the case of tuberculosis, and other communicable diseases like HIV, there is powerful evidence that it is far more cost-effective in the long term to provide free treatment to all.3 Of course, as Shin suggests, money spent treating a migrant cannot be spent on a UK national. However, the opportunity costs of treating in terms of suffering, spread of disease, and long-term needs will be greater to the NHS, and to the UK, in reduced economic, social and political contributions. Also, the administrative costs of billing and recouping the costs of care under the Immigration Act 2014 will be considerable, as detailed in our initial paper. Notably, the terms ‘migrant’ and ‘health tourist’ are complex because of the absence of standard definitions, with even different government departments themselves employing the terms in ways that result in different data depending on the selected definition.4 Our statements employ definitions that are consistent to enable meaningful comparison, and the studies we drew upon also adopted consistent classifications. Troublingly, Shin himself collapses definitions, wrongly folding Trust policies on overseas patients (i.e. visitor, non-residents) into a discussion of amendments that affect broader populations that also includes all non-EEA temporary migrants, many of whom will have been in the UK for years, rather than days; a population who will be hit hard by the Immigration Act 2014. We therefore encourage a focus not on entitlement, but on care and treatment on the basis of
need; values that rightly sit at the heart of all medical practice and the NHS itself. Declarations Competing interests: None declared
References 1. Dustmann C and Frattini T. The fiscal effects of immigration to the UK. CReAM DP 2013; 22: 13. 2. Coker R. Lessons from New York’s tuberculosis epidemic. BMJ 1998; 317: 616–620. 3. Select Committee on Health. Charges for Overseas Visitors for HIV/AIDS treatment. Third Report. 2005; [online]. See http://www.publications.parliament.uk/pa/ cm200405/cmselect/cmhealth/252/25206.htm#n128 (last checked 1 October 2014). 4. Bhopal RS. Migration, Ethnicity, Race, and Health in Multicultural Societies. Oxford: Oxford University Press, 2013.
Sarah Steele Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK Email: [email protected]
David Stuckler Department of Sociology, University of Oxford, Oxford, UK
Martin McKee London School of Hygiene and Tropical Medicine, London, UK
Allyson M Pollock Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
Downloaded from jrs.sagepub.com by guest on August 13, 2015
To submit a letter in response to a JRSM article, please visit http://jrsm.sagepub.com to find the article concerned, then click on the ‘Submit a comment’ link found in the Reader Responses section. Comments will automatically be submitted for consideration to be published in print.
We must recognise the actual and opportunity costs of treating immigrants in the NHS I am surprised by Steele et al.’s article decrying the health aspects of the Government’s Immigration Bill 2013–2014.1 The authors work in East London, as I do. They should therefore be well aware of the burden of infectious diseases associated with London’s immigrant populations, e.g. tuberculosis (TB), HIV and viral hepatitis. Treating these infections is costly. For example, treating Extensively Drug Resistant TB (XDR-TB), which occurs mostly in immigrants, is very expensive compared to drugsensitive TB.2 Some of the statistics quoted are questionable. The authors state that ‘immigrants account for 4.5% of the population of England’. However, the 2011 Census stated that 9.4% of the population of England are immigrants.3 Health tourism is a vague term. It refers both to wealthy foreigners availing themselves of UK private healthcare and to NHS healthcare provided to immigrants not entitled to free care. The former is beneficial to the UK, the latter is not. Like the authors, I am aware of the potential benefits of immigration. The NHS could not function without its foreign staff. However, unlike the authors (perhaps), I recognise the significant costs of treating immigrants. We must recognise the opportunity cost of expending limited NHS resources on those who are not entitled to it. Every pound spent on immigrants not entitled to free NHS care is a pound we cannot spend on Britons who are entitled to this care. As public servants, we have a responsibility to ensure that publicly funded resources are expended properly on those who are entitled to it. Finally, most NHS Trusts, including the authors’ local NHS Trust (Barts Health), have an overseas patient policy which requires staff to identify patients not entitled to free NHS care. These policies apply to all NHS Trust staff and for good reason. Declarations Competing interests: I work for Public Health England (PHE), an executive agency of the Department of Health. I am a civil servant
writing in support of this Government immigration policy; I do so of my own free will.
References 1. Steele S, Stuckler D, McKee M and Pollock A. The Immigration Bill: extending charging regimes and scapegoating the vulnerable will pose risks to public health. J R Soc Med 2014; 107: 132–133. 2. Pooran A, Pieterson E, Davids M, Theron G and Dheda K. What is the cost of diagnosis and management of drug resistant tuberculosis in South Africa? PLoS One 2013; 8: e54587. 3. Office for National Statistics. 2011 UK Census: Country of Birth, Local Authorities in England and Wales (Table KS204EW). London, UK: Office for National Statistics.
Gee Yen Shin Public Health England, Department of Infection, 3/F Pathology and Pharmacy Building, The Royal London Hospital, 80 Newark Street, London E1 2ES, UK Email: [email protected]
Authors’ response to Shin: We must recognise the actual and opportunity costs of treating immigrants in the NHS In our paper, we noted explicitly that the Government’s proposals are politically motivated, rather than practically. Hence, it is unsurprising that there are some, such as Gee Yen Shin, who take a different view about the UK’s responsibilities to migrants who come to this country. There is a considerable mythology that has grown up around the costs of illegal immigrants and abuse of services, which has been refuted.1 However, our article notably focused on the practical implications of this political decision, both for migrants and the public at large. Is Shin really suggesting that patients should go untreated because they are no longer entitled to ‘free care’? In the context of tuberculosis, it is useful to recall the epidemic that occurred in New York in the 1980s and 1990s, which included multidrug-resistant outbreaks, and that eventually cost more than US$1 billion to address.2 Such an epidemic in the UK would certainly be undesirable, both in terms of its
! The Royal Society of Medicine 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav Downloaded from jrs.sagepub.com by guest on August 13, 2015
Shin
467
human and economic costs. Indeed, while small amounts of savings for the NHS might appear justifiable in the short term, in the case of tuberculosis, and other communicable diseases like HIV, there is powerful evidence that it is far more cost-effective in the long term to provide free treatment to all.3 Of course, as Shin suggests, money spent treating a migrant cannot be spent on a UK national. However, the opportunity costs of treating in terms of suffering, spread of disease, and long-term needs will be greater to the NHS, and to the UK, in reduced economic, social and political contributions. Also, the administrative costs of billing and recouping the costs of care under the Immigration Act 2014 will be considerable, as detailed in our initial paper. Notably, the terms ‘migrant’ and ‘health tourist’ are complex because of the absence of standard definitions, with even different government departments themselves employing the terms in ways that result in different data depending on the selected definition.4 Our statements employ definitions that are consistent to enable meaningful comparison, and the studies we drew upon also adopted consistent classifications. Troublingly, Shin himself collapses definitions, wrongly folding Trust policies on overseas patients (i.e. visitor, non-residents) into a discussion of amendments that affect broader populations that also includes all non-EEA temporary migrants, many of whom will have been in the UK for years, rather than days; a population who will be hit hard by the Immigration Act 2014. We therefore encourage a focus not on entitlement, but on care and treatment on the basis of
need; values that rightly sit at the heart of all medical practice and the NHS itself. Declarations Competing interests: None declared
References 1. Dustmann C and Frattini T. The fiscal effects of immigration to the UK. CReAM DP 2013; 22: 13. 2. Coker R. Lessons from New York’s tuberculosis epidemic. BMJ 1998; 317: 616–620. 3. Select Committee on Health. Charges for Overseas Visitors for HIV/AIDS treatment. Third Report. 2005; [online]. See http://www.publications.parliament.uk/pa/ cm200405/cmselect/cmhealth/252/25206.htm#n128 (last checked 1 October 2014). 4. Bhopal RS. Migration, Ethnicity, Race, and Health in Multicultural Societies. Oxford: Oxford University Press, 2013.
Sarah Steele Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK Email: [email protected]
David Stuckler Department of Sociology, University of Oxford, Oxford, UK
Martin McKee London School of Hygiene and Tropical Medicine, London, UK
Allyson M Pollock Centre for Primary Care and Public Health, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
Downloaded from jrs.sagepub.com by guest on August 13, 2015
