British Medical Association – Written evidence (FAM0081) 

About the BMA

The BMA is a professional association and trade union representing and negotiating on behalf of all doctors and medical students in the UK. It is a leading voice advocating for outstanding health care and a healthy population. It is an association providing members with excellent individual services and support throughout their lives.

Summary

• The BMA welcomes the opportunity to respond to the Lords Justice and Home Affairs and Justice Committee’s inquiry looking at family migration pathways in the UK.
• In particular, we are grateful for the opportunity to raise our concerns over the impact of the current restrictive adult dependent relative rules on healthcare workers and the NHS.
• The BMA has been calling for the removal of the adult dependent relative rules for healthcare workers, as set out in a letter to the Home Secretary we wrote jointly with BAPIO, APPNE, RCGP, RCOG, RCPsych and RCOphth[1] in January 2021.
• The policy can have a profound impact on doctors’ wellbeing, with 91% of respondents to a 2020 survey ran by BAPIO and APPNE reporting feelings of anxiety stress and helplessness due to the issue.[2] 
• There is also a risk to the NHS if talented international doctors, the UK has often spent money on training, choose to relocate if they are unable to look after their elderly dependent family members in the UK. The same survey found of the nearly 1,000 doctors surveyed, 8 in 10 were considering relocating due to the restrictive rules.[3]
• In the context of severe staff shortages and a record-breaking care backlog, this would be disastrous for the NHS and patients, and would put even more pressure on already burnout healthcare workforce.
• The Government has argued that the rules are in place to stop adult dependent relatives coming to the UK and being an economic burden to the UK taxpayer. However, given the cost it takes to train a doctor in the UK, it makes little economic sense to risk losing them from the health service altogether.

1. Current immigration pathway for adult dependent relatives

1.1 Under the current immigration rules introduced in 2012, British citizens with elderly parents are only allowed to have their dependent parents join them if they can demonstrate that they require a level of long-term personal care that they are unable to get in their home country, either due to cost or availability. Those who meet the new requirements are granted Indefinite Leave to Enter if their sponsor is a British citizen or settled here, subject to the sponsor agreeing that they will maintain and accommodate and, under the new rules, care for their relative without access to public funds for at least a five-year period.[4]

1.2 Reaching the threshold of evidence required to prove that adult dependents’ care needs can only be met by their sponsor in the UK is often very difficult for applicants to do. Data[5] shows that from 1.3 2017 across a four-year period, of 908 visa applications made to the Home Office under the Adult Dependent Relative rule, only 35 were approved at the first attempt - this equates to 1 in 25.  Others that were issued were only done so following a lengthy appeal or the decision being overturned in court. In 2017, the Home Office didn’t issue a single adult dependent relative (ADR) visa.

1.4 The Government has argued that the rules are in place to stop adult dependent relatives coming to the UK and being a burden to the UK taxpayer. However, alternative methods of avoiding any burden on the NHS and on local authorities are likely to be available in some ADR cases. For example, these could include the Immigration Health Surcharge introduced under the Immigration Act 2014, medical insurance or a bond, as in the case of the Canadian, Australian and New Zealand schemes for elderly migration.

1.5 The proportion of people needing to bring their elderly dependents to the UK is also very small in the context of overall immigration. Before the rule change in 2012, the total applications constituted approximately 0.0069 % of total immigration to the UK and 0.011% of all non-EU immigration.[6] However, the impact on individuals effected by the rules has been profound and disproportionate.

2. Impact on doctors and the wider NHS

2.1 We are deeply concerned that this rule is having an adverse impact on the lives and mental wellbeing of our members with elderly dependent parents living abroad. The BMA has heard from doctors who feel that their right to a family life is being disregarded, resulting in a feeling of despair and a risk of burnout.[7]

2.2 A survey of nearly 1,000 doctors carried out by BAPIO and APPNE’s in August found 91% of survey respondents reported feelings of anxiety, stress and helplessness due to this issue. Sixty per cent (60%) told the survey these feelings were having an adverse effect on their working lives.

2.3 The pressures these doctors are facing have been further exacerbated by the COVID-19 pandemic, a record care backlog, continued staffing shortages, sustained pay erosion and the pension taxation trap[8]; all of which have left the healthcare workforce at high risk of burnout and considering leaving the profession early. For doctors with dependent adult relatives living abroad, the inability to look after their relatives in the UK is simply an added cause of stress and barrier to continuing to live and work in the UK. 

2.4 Doctors in this situation forced to take leave, and even make multiple journeys, at a time when our NHS needs their dedication and experience more than ever. It has also concerningly led to some healthcare professionals considering leaving the UK – according to the BAPIO/APPNE 2020 survey, a staggering 85% of respondents admitted they had considered either returning to their home countries or relocating to one with more flexible regulations on ADR immigration. Last year, the BMA reported on[9] a doctor who had spent years working in the UK and became a British citizen in 2014. After months of battling with the Home Office to win the right to bring his mother to the UK, he concluded that he had no other choice than to leave the NHS and relocate himself and his family to Australia.

2.5 The NHS is already facing a workforce crisis as highlighted by the Health and Social Care Committee’s recent workforce inquiry.[10] BMA estimates show England would need the equivalent of an additional 46,300 full time doctors simply to put us on an equivalent standard with today’s OECD EU average of 3.7 doctors per 1,000 people.[11] In the midst of a workforce crisis and a record NHS backlog with over 6.84 million people waiting for treatment,[12] the NHS simply cannot afford to lose these talented, experienced doctors.

2.6 Furthermore, there is no statistical evidence to suggest that the cost of lifting these restrictions for healthcare workers in the NHS would be a burden to the taxpayer. Perversely, the potential loss to the NHS if these doctors, many of whom the UK has spent money on training, feel they are forced out of the country due to their inability to care for their elderly parents in the UK, would likely be far greater.

2.7 The cost of training a nurse is £51,000 for every nurse, a junior doctor is £230,000 and a consultant or a GP is about £500,000. Equally, the loss of one trained Consultant to GP is £500,000 excluding loss of taxes to the exchequer and excluding spend on replacement, which could include expensive locum costs.

2.8 Politicians have repeatedly pointed to international medical graduates (IMGs) as at least part of the answer to addressing the NHS workforce crisis. International healthcare workers already play a hugely important role in the running of the NHS, making up around 15% of the NHS workforce and 22% of doctors.[13]  International doctors already face significant barriers to living and working in the UK. For instance, limited support networks, lack of familiarity with the NHS and the complex health and social care system in England. The adult dependent relative rules are yet another potential barrier or deterrent to international doctors working the UK and we are at real risk of IMG doctors choosing to live elsewhere. Added to the context of the cost-of-living crisis and the sustained pay erosion doctors have faced since 2008/09, there is a real risk doctors may increasingly see the UK as a less favourable option. 

2.9 These rules will now also apply to EU citizens arriving to live in the UK post Brexit, posing the very real risk that they will deter doctors from EU countries from choosing to work in the UK, in favour of countries with more lenient rules. We are extremely concerned about the potential impact on patient care and the wider NHS if doctors choose to relocate, or not come to the UK at all, due to these restrictive rules.

3. International comparisons

3.1 The Government has argued that the rules are in place to stop adult dependent relatives coming to the UK and being a burden to the UK taxpayer. However, alternative methods of avoiding any burden on the NHS and on local authorities can be achieved under a more flexible system. Countries such as Australia and New Zealand have adopted a pragmatic approach to adult dependent relatives, including the elderly parents of its migrant workforce who settle there. These systems have a variety of safeguards in place such as including a requirement for the applicant to assure the immigration authorities that they will not have to rely on government assistance after they enter the country.

3.2 Australia for example, offers a permanent visa to an adult dependent relative, such as an elderly parent who relies on a relative living in Australia for financial support, on the condition they are sponsored by their relative and are dependent on them for basic needs. This includes being dependent on a relative due to disability. Similarly, in New Zealand permanent residency can be granted if the sponsor of an elderly parent can provide suitable accommodation and ensure their health and welfare needs are met.

3.3 The more flexible approach taken by international comparators, as highlighted above, has resulted in some medical professionals considering or choosing to relocate to these countries.[14]

4. Summary

4.1 To ensure the UK retains the experienced, talented international workforce it has, we must start to break down the barriers they face to living and staying in the UK. This must include ensuring they are able to care for elderly, dependent relatives without facing the significant anxiety and stress caused by the current restrictive system.

4.2 Not only is this essential to supporting the wellbeing of medical professionals working in the UK, but it is vital to ensuring the UK is able to retain and recruit the staff we need to help address the workforce crisis and record care backlog facing the NHS.

4.3 The BMA strongly urges the Committee to recommend as part of its inquiry that an urgent review of the Adult Dependent Relative rule is carried out with a view to removing them for healthcare workers, so they can continue to care for patients in the UK without sacrificing caring for their elderly dependent relatives overseas.

September 2022