Just a few of the times 'we don't really know' is stated in the report:
All of the estimates presented are subject to varying degrees of uncertainty,
relating to the numbers of people and their behaviour. The estimates for the
irregular migrants are very uncertain and based on out of date population
estimates. The estimates for health tourism, as for any unlawful activity, are
impossible to estimate with confidence and are a structured judgment. The
estimates for chargeability are also uncertain because of the complexity of the
rules. The estimates are presented as the best that can be made at present,
recognising that they are based on incomplete data, sometimes of varying
quality, and a large number of assumptions. The analysis is intended to
inform policy development around visitor and migrant access to NHS,
alongside the DH consultation and work with the NHS.
This is not an audit in the traditional sense but an independent assessment of the
likely numbers and costs as set out in our brief above. The estimates are
presented as what was achievable in the timescale to meet the terms of
reference. The analysis deals with a number of complex and contentious topics
and the results are presented as the best that can be made at present,
recognising that they are based on incomplete data, sometimes of varying
quality, and a large number of assumptions and judgments. The analysis is
intended to inform policy development around visitor and migrant access to
NHS, alongside the DH consultation and work with the NHS.
The depth and completeness of our analysis has been constrained by the time
limitations as well as limitations on the data. The Department of Health is
considering what further work is required to assess the policy options.
These numbers are very uncertain and based on historical population estimates, constrained by the lack of detailed up to date statistics from the Home Office.
As with any irregular activity the numbers are very uncertain and are plausible ranges rather than distinct estimates. These numbers should be used with caution.
The rules are complex and Annex B summarises the extent to which different visitor and migrant groups may be eligible for free treatment in NHS hospitals.
Chargeability is based on complex rules that NHS staff must apply on a case-by-case basis. When the complexity of the rules on charging is overlain on the
uncertainty inherent in the visitor and migrant numbers, the estimates for what
is chargeable become very uncertain when broken down in detail. We have
therefore only been able to make a provisional assessment at this time.
The estimate of the potentially chargeable values is subject to further uncertainty
since the model does not capture the full complexity of the eligibility rules.
More analysis is required to unpick the rules of exactly what is recoverable as the detailed arrangements vary from state to state.
First, the estimates for gross costs (£330m) for the use of the NHS by irregular migrants are very uncertain.
Overall, the indications are that Trusts collect about 15% of the sums that are potentially chargeable to non-EEA patients (excluding irregular migrants). These figures are uncertain and should only be taken as indicative of the scale of under-collection rather than a sound estimate.
The Phase 1 study has had to rely on the voluntary cooperation of the NHS
Trusts. This means that the quantitative values in the results are not appropriate
to apply observations directly to the populations that we have used in our
analysis.
The NHS does not routinely or systematically capture data on the use overseas
visitors and migrants make of the NHS in England. The systems are not centrally
managed and are run differently by Trusts. In addition, there are well known
problems in knowing how many visitors and migrants there are in the UK.
The Office of National Statistics (ONS) undertook an improvement programme
between 2008 and 2012, which has seen an increase in the amount of data to
help understand migration (e.g. the questions in the 2011 Census). However, the
benefits take time to flow through to the published information and significant
shortcomings remain.
“They [migration statistics] are not accurate enough to measure the effect of migration on population, particularly in local areas, and they are not detailed enough to measure the social and economic impacts of migration, or the effects of immigration policy. Current sources of migration statistics were established at a time when levels of migration were much lower than they are today. These sources are not adequate for understanding the scale and complexity of modern migration flows, despite attempts to improve their accuracy and usefulness in recent years.”
Running this study in parallel with the consultation has limited the time
available and this has created some constraints on the study, including:
A cut-off date for new data of 20 August
Reduced time to validate data sources so reliance on proven data such as
the Census and IPS
No time to generate specific reports from ONS
No time to engage widely with other researchers
We recognise that these constraints have limited the extent of analysis and the
results are presented with that in mind.
There is very little from the quantitative literature that measures
attendance/activity rates either in primary or secondary care compared to the
non-migrant UK population for specific migrant groups.
Empirical knowledge on the magnitude and effect of health tourism is lacking.
No research was identified on healthcare use amongst expatriates.
Studies assessing migrant healthcare use are limited by poor reporting systems
and difficulties in identifying individuals who are born outside of the host
country within healthcare databases. European studies show that data
availability is a problem across many countries with many having no specific
data recording systems Many studies identify migrants through proxy
measures, which can lead to misclassification. There is also a lack of research at a
national level and many studies are only applicable to local settings. Additionally
studies tend to be cross-sectional in design and give a snapshot of healthcare use
that is likely to change over time. Overall findings will mask variations in
healthcare use amongst different migrant populations. The focus of academic
research within the UK has traditionally been on ethnicity and health, although
the effects of being born outside of the UK are being studied more now.
“It had been proposed that the initial estimates of migrant consumption of
education, health, social services and social care and their costs, would be
adjusted in the light of the literature review. However, in practice, the
literature did not provide sufficiently reliable data or estimates to do so in a
way likely to improve the accuracy of our estimates, so we did not do so.”
We have simplified the problem and interpolated missing data. The analysis
is dealing with a fractal problem in that at every level new layers of
complexity are found at the layer below. This is true for the population data,
DH costing, definitions of migrant and the rules on eligibility for free
treatment. Since information is very often missing at the lower levels, we
have been interpolating missing figures. In some cases the analysis uses
assumptions to apportion uncertain data within known totals. The result is
that the analysis is reasonably robust at the aggregated level, but does
become increasingly uncertain as it is broken down.
At this point I got tired of cutting and pasting.....https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/251909/Quantitative_Assessment_of_Visitor_and_Migrant_Use_of_the_NHS_in_England_-_Exploring_the_Data_-_FULL_REPORT.pdf
