Impact assessment

Immigration Health Surcharge: equality impact assessment 2023 (accessible)

Published 19 October 2023

1. Name and outline of policy proposal, guidance, or operational activity

Increasing the full rate of Immigration Health Charge to £1,035 per year and the discounted rate to £776 per year.

Background

The Immigration Health Charge was introduced to ensure that migrants contribute to the cost of healthcare provided by the NHS. Prior to the introduction of the Health Charge, temporary non-EEA nationals, in the UK for six months or more, could access NHS treatment on the same basis as UK nationals for the duration of their stay. The NHS entitlement rules in place prior to the introduction of the Health Charge provided a cost burden on NHS resources. In 2013, the estimated cost of treating non-EEA nationals was around £1 billion annually, which placed a significant burden on NHS resources.

The Immigration Act 2014 provided the Secretary of State the power to impose the requirement to pay a Health Charge on migrants applying for temporary immigration permission. The Immigration (Health Charge) Order 2015 (the Order) outlined the level of the Health Charge, the way the Health Charge is calculated (i.e., that the Health Charge is charged in six-month blocks and is based on the duration of immigration permission applied for), consequences of failure to pay the required Health Charge and exemptions from charge for certain cohorts.

On 6 April 2015, The Order introduced a requirement that temporary migrants who make an application to come to the UK for more than six months, or to extend their stay in the UK, pay an Immigration Health Charge, unless they are subject to an exemption. At inception the Health Charge applied solely to temporary non-EEA migrants. Having paid the Health Charge, migrants may access the NHS on broadly the same basis as UK residents for the duration of their immigration permission in the UK. The total Health Charge that a temporary migrant is required to pay, is based on the duration of the immigration permission applied for. In 2015, the Health Charge rate was set at £200 per person, per year for most applications, with a discounted rate for students and their dependants set at £150 per person, per year. The Health Charge rates in 2015 represented around 25% of the average per capita cost to the NHS of treating Health Charge payers.

Additionally, the Order allows for specified cohorts to be exempt from payment of the Health Charge. These exemptions are broadly based on UK treaty obligations, international agreements, and previous ministerial commitments. The exemptions from charge include protection cohorts such as asylum seekers and victims of human trafficking and cohorts exempt on the basis of international agreements such as the Agreement on the withdrawal of the United Kingdom of Great Britain and Northern Ireland from the European Union and the European Atomic Energy Community. Certain migrants employed in the Health and Care Work sectors are also exempt, due to the contributions they make to the NHS through their work.

Overtime, the Health Charge policy has developed alongside the wider immigration system. On 6 April 2016, the Youth Mobility Scheme became subject to the discounted rate and the exemption from payment of the Health Charge which applied to nationals of Australia and New Zealand was removed.

On 6 April 2017, a new exemption was added to explicitly exempt Victims of Modern Slavery from payment of the Health Charge, to reflect the vulnerability of the cohort. At the same time the exemption from charge for Intra-company transfer migrants was removed.

On 8 January 2019, the Health Charge was increased to £400, with the discounted rate for students, their dependants, and applicants for the Youth Mobility Scheme increasing from £150 to £300.

The Government’s manifesto, in 2019, committed to increasing the Health Charge to a level which broadly covered the average cost to the NHS of treating Health Charge payers.

On 1 October 2020 the Health Charge full rate was increased to £624, and the discounted rate increased to £470 for students, their dependents, and applications to the Youth Mobility Scheme. The Government recognised that increasing the Health Charge may have a larger financial impact on families than individuals. Therefore, children under the age of 18 also became subject to the discounted rate.

Following the UK’s exit from the European Union, EEA nationals became subject to immigration control from 1 January 2021, unless eligible for the EU Settlement Scheme (EUSS). EEA nationals are required to pay the Health Charge when making an immigration application to work, study or join family unless eligible for the EUSS.

The amendments to the Immigration (Health Charge) Order 2020 also exempted those working in the Health and Care sector from payment of the Health Charge. Migrants sponsored on the Health and Care Work visas are exempt from payment of the Health Charge upfront, whereas migrants with a general right to work which is not tied to a specific sector or role can claim reimbursement for periods they were employed in the Health and Care sector.

Policy Proposal

The Government is aiming to amend the Immigration (Health Charge) Order to increase the Health Charge from £624 to £1,035 per person per year, with the discounted rates for students, their dependents, applicants for the Youth Mobility Scheme and children under the age of 18 increased from £470 to £776 per person per year. The Health Charge increase will apply to immigration applications made on or after the date the amended Order comes into force.

The increase continues to deliver the 2019 manifesto commitment to ensure that the Health Charge reflects the full cost to the NHS of treating Health Charge payers. The increases to the Health Charge will ensure that the full cost of providing NHS services for those who pay the Health Charges are covered.

The Immigration Rules currently provide for exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless immigration route. It is therefore intended to formalise these exemptions from payment of the Health Charge, in legislation. The Health Charge has been waived for applicants on the Ukraine Schemes since the inception of the schemes in March 2022, following the Russian invasion of Ukraine. Formalising the exemption will solidify the support for Ukrainian nationals, align the Immigration (Health Charge) Order 2015 with the Immigration Rules, and deliver the will of parliament.

The Stateless immigration route provides a pathway for migrants to regularise their stay within the UK where they are not recognised as a citizen or remain permanently in any country. The Health Charge has not applied to applications for the Stateless immigration route since inception, in line with equivalent provisions for asylum seekers.

The Government also plans to update the legislation to replace obsolete terminology in the Order with current terminology ensuring consistency with the Points Based Immigration System.

Who will be affected?

The Health Charge is paid by migrants who apply to enter the UK to work, study or join family for six months or more. It is also paid by migrants applying to extend their temporary immigration permission in the UK. Visa Applications made on or after the commencement date of the Order will be required to pay the Health Charge at the increased rate.

The Health Charge is set at a fixed amount which takes no account of an individual’s usage. The charge is based on how much healthcare an ‘average’ Health Charge payer is expected to use and not directly linked to the healthcare usage of each individual payee. This is likely to benefit those who use the NHS more than average, for example those with pre-existing health conditions (which could be young people of working age), pregnant women and the elderly. All migrants who are liable to pay the Health Charge must pay upfront and in full, covering the duration of the immigration permission applied for.

Formalising the exemption from payment of the Health Charge provides legal protections for these cohorts affected and ensures that legislation clearly specifies those that are exempt from the Health Charge.

The Ukraine Schemes are comprised of the Ukraine Family Scheme, the Homes for Ukraine Scheme and the Ukraine Extension Scheme. The Ukraine Family Scheme provides Ukrainian nationals (and their dependants) with family members in the UK who hold permanent status, the ability to join family. The Homes for Ukraine Scheme enables Ukrainian nationals to live with approved sponsors within the UK and the Ukraine Extension Scheme permits applicants to remain in the UK if they have an existing immigration permission. Between the inception of the Ukraine Schemes and March 2023 there were 233,771 grants of leave on the Ukraine Schemes. Since the inception of the Stateless immigration route there have been around 1,000 applications.

2. The Public Sector Equality Duty

1. The public sector equality duty (PSED) under s149 of the Equality Act 2010 provides that public authorities must, when exercising their duties, have due regard to the need to:

(1) Eliminate discrimination, harassment, victimisation and any other conduct prohibited by the Act

(2) Advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it

(3) Foster good relations between persons who share a relevant protected characteristic and persons who do not share it

2. This PSED covers the following nine protected characteristics: age; disability; gender reassignment; pregnancy and maternity; race (including ethnic or national origins, colour or nationality); religion or belief; sex; marriage and civil partnership and sexual orientation.

3. Marriage and civil partnership is not a “relevant characteristic” for the purposes of limbs (2) and (3) of the duty. It is a protected characteristic for the purposes of limb (1), but only the in the context of employment.

4. Schedule 18 to the 2010 Act sets out exceptions to the public-sector equality duty. In relation to the exercise of immigration and nationality functions, s149(1)(b) of the Act (to advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it) does not apply to the protected characteristics of age, race (insofar as it relates to nationality or ethnic or national origins) or religion or belief.

5. Paragraph 2(1) (Part 1) of Schedule 3 to the 2010 Act provides that the prohibitions against unlawful discrimination provided for by virtue of section 29 of the 2010 Act do not apply to the preparing, making, approving or consideration of particular forms of secondary legislation. However, this EIA demonstrates compliance with the PSED in regard to the formulation of the policy behind these legislative changes. This EIA builds on the equalities considerations which have been undertaken since the introduction of the Health Charge.

6. Schedules 3 and 23 to the 2010 Act operate so that certain discrimination in relation to age, nationality, national or ethnic origins, or place or duration of evidence does not amount to unlawful discrimination. This includes where the discrimination is authorised by the Immigration Rules or by primary or secondary legislation. For example, a Home Office official will not be in breach of section 29 of the 2010 Act on grounds of age discrimination by applying the full rate of the Health Charge to an adult or the reduced rate to a child, nor will they be in breach of section 29 on grounds of nationality discrimination by applying the exemption from the charge to an application for leave to enter or remain made under Appendix Ukraine Scheme. This is because the caseworker will be acting in accordance with the Immigration (Health Charge) Order 2023.

7. However, it is still necessary to consider the justification for the discrimination and the impact on equalities as a matter of public law. This Equality Impact Assessment therefore considers all the proposals through the framework of the 2010 Act.

8. No evidence of unlawful discrimination, harassment or victimisation of any group has been identified during the course of our analysis. However, there are instances where individuals of a certain protected characteristic are likely to be more impacted by the proposed changes. Further detail is below.

3. Summary of the evidence considered in demonstrating due regard to the Public-Sector Equality Duty.

To produce this Equality Impact Assessment (EIA) officials considered a range of factors and data from various sources, comprising of Government and external information.

Applicants liable to pay the Health Charge

The Health Charge applies to most UK immigration routes unless an exemption from payment of the Health Charge applies. The Health Charge paid is specific to the visa application, for visas for both entry clearance and permission to stay. Therefore, migrants applying for further temporary visas to extend their immigration permission within the UK will be required to pay the Health Charge covering the duration of the further immigration permission.

Data from the published migration statistics provides information regarding the nationality breakdown of visa applicants for work, study and family applications since the current rates of Health Charge were implemented in 2020. Table 1 below provides the continental breakdown of entry clearance visa applicants and Table 2 provides information on the nationalities with the highest visa grants in the same period for each broad category of Entry Clearance.

Table 1 – Entry Clearance visa volumes by region^{[footnote 1]}

Study (main applicants and dependents)

	Year ending June 2023	Year ending June 2022	Year ending June 2021
Africa	146,421 (22.4%)	80,606 (16.6%)	30,271 (10.8%)
Asia	444,872 (68.2%)	345,465 (73.7%)	223,201 (79.4%)
Europe	32,352 (5%)	32,145 (6.6%)	8,135 (2.89%)
North America	20,741 (3.2%)	19,958 (4.1%)	12,680 (4.51%)
Oceania	1,514 (0.2%)	1,080 (0.2%)	970 (0.3%)
South and Central America	5,933 (0.9%)	5,897 (1.2%)	3,789 (1.34%)
Total applications	652,689	486,868	281,008

Work (main applicants and dependents)^{[footnote 2]}

	Year ending June 2023	Year ending June 2022	Year ending June 2021
Africa	152,410 (28.3%)	48,835 (14.7%)	25,068 (14.6%)
Asia	281,769 (52.3%)	185,290 (55.9%)	82,022 (47.7%)
Europe	53,974 (10%)	61,460 (18.6%)	41,617 (24.2%)
North America	18,332 (3.4%)	16,008 (4.8%)	12,638 (7.3%)
Oceania	20,988 (3.9%)	11,006 (3.3%)	4,766 (2.8%)
South and Central America	10,809 (2%)	7,913 (2.4%)	4,380 (2.5%)
Total Applications	538,887	331,233	172,045

Family

	Year ending June 2023	Year ending June 2022	Year ending June 2021
Africa	16,627 (22%)	9.053 (24.8%)	11,162 (23.3%)
Asia	43,368 (57.2%)	19,785 (54.3%)	27,426 (57.3%)
Europe	6,525 (8.6%)	2,570 (7%)	2,374 (5%)
North America	4,162 (5.5%)	2,379 (6.5%)	2,883 (6%)
Oceania	1,334 (1.8%)	663 (1.8%)	689 (1.4%)
South and Central America	3,173 (4.2%)	1,374 (3.8%)	1,781 (3.7%)
Total Applications	75,717	36,470	47,833

Table 2 – Highest visa nationalities – entry clearance grants^{[footnote 3]}

	Year ending June 2023	Year ending June 2022	Year ending June 2021
Study (Main applicants and dependents)	India 186,400 Nigeria 126,196 China 108,365 Pakistan 40,203 Bangladesh 20,224	India 117,965 China 115,056 Nigeria 65,929 Pakistan 23,490 USA 16,137	China 95,408 India 62,646 Nigeria 20,427 USA 10,047 Pakistan 9,733
Work (Main applicants and dependents)	India 157,771 Nigeria 63,850 Zimbabwe 39,909 Philippines 28,712 Pakistan 20,917	India 110,647 Nigeria 17,491 Philippines 21,867 USA 11,141 Zimbabwe 8,559	India 45,632 Philippines 11,028 USA 8,913 Nigeria 8,420 Pakistan 4,605
Family	Pakistan 14,315 India 5,500 Bangladesh 3,497 USA 3,467 Nepal 3,181	Pakistan 5,908 India 2,387 USA 2,033 South Africa 1,656 Iran 1,496	Pakistan 8,685 India 3,621 USA 2,439 Bangladesh 2,423 South Africa 1,968

The data in Table 1 and Table 2 highlights that a significant volume of entry clearance visas in work, study and family routes are associated with a small number of nationalities. In the year ending June 2023, the top five nationalities for sponsored study applications by main applicants and dependents accounted for 73.8% of all sponsored study applications. Similarly, the top 5 nationalities granted work and family visas account for 57.5% and 35.4% respectively of total entry clearance grants. Due to the high proportion of visas issued to a small proportion of nationalities, increases to the Health Charge are likely to have a higher impact on applicants from certain nationalities.

Some nationalities are represented across the top five nationalities for visa grants under study, work and family routes, meaning that increases to the Health Charge may have higher impacts on these nationalities. However, for work especially, the volumes of visa grants will not fully align with Health Charge payers, certain immigration routes within the broad work category will not pay the Health Charge. For example, the Health and Care Worker visa accounted for 259,289 grants of entry clearance (121,290 main applicants and 137,999), meaning nationalities which account for significant volumes of grants on the Health and Care visa (India, Nigeria, Zimbabwe) may not be impacted as highly.

Table 3 below provides the continental breakdown of visa applications for further immigration permission from within the UK.

Table 3 – Permission to stay volumes by region

Study (main applicants and dependents)

	Year ending June 2023	Year ending June 2022	Year ending June 2021
Africa	9,133 (13.7%)	5,354 (16.4%)	7,169 (19.1%)
Asia	51,531 (77.5%)	24,563 (73%)	25,975 (69.5%)
Europe	2,362 (3.5%)	1,237 (3.7%)	1,075 (2.9%)
North America	2,237 (3.4%)	1,625 (4.8%)	2,157 (5.8%)
Oceania	236 (0.4%)	248 (0.7%)	285 (0.8%)
South and Central America	952 (1.45%)	623 (1.9%)	902 (2.4%)
Total applications	66,459	33,653	37,387

Work (main applicants and dependents)

	Year ending June 2023	Year ending June 2022	Year ending June 2021
Africa	96,953 (22.6%)	36,079 (15%)	15,439 (11.4%)
Asia	274,982 (64.2%)	161,581 (67.1%)	87,892 (65.1%)
Europe	29,427 (6.9%)	19,165 (8%)	12,080 (8.9%)
North America	14,730 (3.4%)	12,844 (5.3%)	10,393 (7.7%)
Oceania	4,325 (1%)	5,323 (2.2%)	5,591 (4.1%)
South and Central America	7,667 (1.8%)	5,762 (2.4%)	3,669 (2.7%)
Total Applications	428,162	240,790	135,078

Family

	Year ending June 2023	Year ending June 2022	Year ending June 2021
Africa	40,311 (30.9%)	31,639 (25.3%)	33,924 (28.6%)
Asia	65,538 (50.3%)	68,008 (54.3%)	60,178 (50.7%)
Europe	10,049 (7.7%)	9,908 (7.9%)	7,873 (6.6%)
North America	4,921 (3.8%)	6,313 (5%)	6,480 (5.5%)
Oceania	1,812 (1.4%)	2,555 (2%)	2,806 (2.4%)
South and Central America	7,327 (5.6%)	6,516 (5.2%)	7,224 (6.1%)
Total Applications	130,255	125,149	118,688

In line with the breakdown of entry clearance visas, Table 3 highlights that the volumes of visa extensions granted per region is also heavily weighted towards applicants from Asia and Africa with around 80% of extensions granted being submitted by migrants from these regions. Due to the entry clearance visas also being heavily weighted towards migrants of Asian or African origin, it is unsurprising to see extension applications following a similar pattern. For in-country applications, due to switching it is difficult to ascertain whether migrants granted under a pathway (e.g. study) continue on that pathway or switch into a different route, as such there is limited value in determining the most common nationalities for further applications.

NHS admissions and cost

The NHS publish information annually on NHS usage which includes demographic information such as age, gender and religion. The data however does not differentiate between the migrant community and the resident populace.

The GP patient survey conducted by NHS England highlights the demographic split of GP Registrations, Figure 1 below highlights the sex split of individuals registering with GP practices in England, the data is based on around 750,000 responses. The data highlights that 52% of respondents were female with 47% of registrations being male.

The split of GP registrations recorded in the survey does not fully align with the sex of visa applicants. Home Office data for Entry Clearance applications between March 2021 and March 2023 highlights that 49% of Health Charge payers were female with 51% of Health Charge payers being male. Figure 2 provides the sex breakdown of the UK populace as per the 2021 Census and the breakdown of sex for Health Charge payers between March 2021 and March 2023. The demographic split of Health Charge payers in relation to sex is broadly similar to the overall populace of the UK.

Figure 1 – Sex of GP registrations^{[footnote 4]}

Female	52%
Male	47%
Non-binary	0%
Prefer to self-describe	0%
Prefer not to say	1%

Figure 2 – Census and Health Charge Payer Sex

Sex	Census	Census (migrant)	Home Office data (IHS payers)
Male	49%	50%	51%
Female	51%	50%	49%

NHS digital undertakes annual research on the volumes of hospital admissions, critical care admissions and admissions requiring consultants, the data for 2022-23 was published on 21 September 2023.

Figure 3 provides the age and gender breakdown of hospital admissions for 2022-23. The data highlights that the volume of hospital admissions increase substantially beyond the age of 50, individuals who are in the age group of 75-79 accounted for 1.9 million admissions constituting 9.5% of all admissions in 2022-23. The likelihood of being admitted to hospital increases after the age of 50, individuals aged over 50 accounted for 64% of all hospital admissions in 2022-23.

Female patients accounted for 10.9 million admissions, accounting for 54.7% of the total admissions. When age and sex are viewed in combination, the volume of admissions is broadly similar for males and females for each age category, except for treatment for individuals between 20-39 where females are significantly more likely to seek hospital treatment. Females between the age of 20-39 are 2.5 times as likely to be admitted to hospital than males in the same age band. This can be explained predominantly due to maternity services as 20-39 would be the prime age for admissions to access maternity services.

In the period of March 2021 to March 2023, more than half of Health Charge payers (including dependants) were aged between 20 and 29 (52%). This represents a significantly larger proportion than the UK population as a whole (13%), or those who identified as a migrant as part of the census (34%).

More than 75% of Health Charge payers (including dependants) were of working age (20-64). As Health Charge payers are generally younger than the resident populace, they are potentially less likely to access NHS services. NHS England publishes “Age-cost curves” which show the relative costs of healthcare in selected settings for different age and gender cohorts.^{[footnote 5]} This data is for the general population of England; it is not known whether migrants in the same age-gender categories as the England population impose similar costs on the NHS. The age and gender profile of migrants is captured in the calculation of the Health Charge to reflect the younger, and so lower cost, profile of the cohort.

Figure 3 – Admissions to hospital split by age^{[footnote 6]}

Age (years)	Male	Female
0 - 4	711673	588871
5 - 9	167756	132200
10 - 14	143051	127316
15 - 19	154285	229573
20 - 24	170814	415724
25 - 29	208729	638857
30 - 34	256967	768851
35 - 39	283181	614958
40 - 44	317619	464092
45 - 49	349538	440182
50 - 54	495336	573247
55 - 59	639661	663770
60 - 64	740793	703635
65 - 69	795157	727187
70 - 74	925476	855520
75 - 79	1007952	967648
80 - 84	761931	798326
85 - 89	547383	639551
90+	297245	463374
Unknown	84262	137822

Figure 4 – Age demographics of Health Charge Payers

Age (years)	Census	Census (migrant flag)	Home Office (IHS payers)
0 - 4	5%	3%	5%
5 - 9	6%	5%	4%
10 - 14	6%	4%	2%
15 - 19	6%	9%	10%
20 - 24	6%	17%	31%
25 - 29	7%	17%	22%
30 - 34	7%	13%	13%
35 - 39	7%	8%	7%
40 - 44	6%	6%	4%
45 - 49	6%	4%	1%
50 - 54	7%	4%	1%
55 - 59	7%	3%	0%
60 - 64	7%	2%	0%
65 - 69	4%	2%	0%
70 - 74	5%	1%	0%
75 - 79	4%	1%	0%
80 - 84	3%	0%	0%
85+	2%	0%	0%

The NHS also publish information pertaining to the tariff which is applied to specific treatments, this provides information on the cost to the NHS of treating conditions which can therefore be attributed to certain cohorts.^{[footnote 7]} Overseas visitors who are not eligible for free treatment are charged at a tariff of 150% of the cost to the NHS of treating patients.

For example, for maternity treatment the cost is differentiated on the basis of duration and intensity of treatment, with the cost graded within six levels. The cost of the delivery phase is between £2,242 and £6,652 with antenatal costs being between £1,107 and £2,947 with post-natal costs of between £233 and £793. Therefore, maternity treatment will cost the NHS a minimum of £3,582 with the highest cost delivery combined with intensive ante-natal and post-natal care coming to £10,392. The cost to the NHS of providing maternity services equates to a total which exceeds the cost of the Health Charge.

Government Research

• Media factsheet: Immigration Health Surcharge

• Immigration system statistics, year ending June 2023 - GOV.UK (www.gov.uk)

• Home Office Analysis and Insight data on age, gender and nationality for the period March 2021 to March 2023.

• https://www.england.nhs.uk/publication/2023-25-nhs-payment-scheme/

• NHS Hospital admission patient information 2021-22

• GP registrations survey 2021-22

• https://www.england.nhs.uk/publication/technical-guide-to-allocation-formulae-and-convergence-for-2023-24-to-2024-25-revenue-allocations/

• Median Weekly Pay by age report 2022

• Department of Health and Social Care gender pay report 2022

• NHS England charging formula 2024-25 (PDF, 2005 KB)

• https://hansard.parliament.uk/Commons/2023-07-13/debates/677D41A0-5A85-4869-8167-69044929D759/PublicSectorPay

• https://www.gov.uk/maternity-pay-leave/pay

External organisation’s research

• World Inequality Report 2022

• Organisation for Economic cooperation and Development information on age range earnings

• University of Oxford Migration Observatory Migrants in the UK wages

• New Policy Institute Disability, long-term conditions and poverty (PDF, 1666KB)

• World Economic Forum Global Gender pay gap Report 2022

• Disability pay gaps in the UK: 2021

• OECD information on disability employment gap

• Families and households in the UK: 2021

• Gender pay gap in the UK: 2022

• Median annual earnings for full-time employees in the United Kingdom in 2022, by age and gender

3a. Consideration of limb 1 of the duty: Eliminate unlawful discrimination, harassment, victimisation and any other conduct prohibited by the Equality Act.

Age

Direct discrimination

Given that the proposed Health Charge increases will be applicable equally to applications subject to the full and reduced rates, we do not consider that there will be any direct discrimination on the grounds of age as a result of these changes.

The Health Charge is set at a lower rate for children under 18, students and applicants for the Youth Mobility Scheme, however, as the full and reduced Health Charge rates are being increased in the same proportion, the discounted rate will continue to be set at 75% of the full rate, we do not consider the increase fundamentally changes the rationale on which those differential charges were originally set, or that it is necessary or proportionate to revisit that rationale in this analysis.

Neither the changes to formally exempt applications for the Ukrainian Scheme and the Stateless immigration route from payment of the Health Charge nor the technical changes to replace obsolete terminology are deemed to impact on the protected characteristic of age.

Indirect discrimination

Younger migrants such as students may be indirectly impacted by the increase to the Health Charge. Individuals in younger age brackets have lower average earnings, statistics for the UK highlight a disparity between the median earnings of individuals between 18-29 contrasted with median earnings for individuals 30-69. Figure 5 shows the median weekly wage per age group, individuals in the 22-29 age bracket have a £546 average weekly wage whereas the average weekly wage for individuals between 40-49 is £727. Data from the Organisation for Economic Co-operation and Development (OECD) also highlight the younger workers globally earn significantly less than the mean earnings of individuals within the prime age bracket of 25-54. For the countries featured, including developed world economies, the reported negative differential for individuals in the 16-24 age band is between 25.5% and 48.6% of the average earnings of individuals in the prime age range.^{[footnote 8]}

The disparity between the median weekly wage may mean that migrants who are under 30 may see higher impacts from the increase to the Health Charge due to lower average wages making saving to pay the Health Charge more difficult. However, students and applicants for the Youth Mobility Scheme are already subject to the discounted Health Charge reflecting the lower earning potential during this period of their careers. It is also important to note that the requirement for migrants to maintain and support themselves is a key tenet of the immigration system, the increased Health Charge does not change this.

Migrants employed in the UK are likely to earn above the UK average. A study conducted by Oxford University Migration Observatory in 2021 highlighted that migrant born employees within the UK labour market earned on average more than the median average for the UK resident population. In fact, with the exceptions of Pakistan and South Asian countries, EU2 countries and EU8, the median annual salary for the migrant born populace exceeded the average for the UK resident populace as a whole. The median salary for the UK resident populace in 2020 was £28,600.^{[footnote 9]} As migrants in the UK may earn more than the national average, this may reduce the scale of impact on migrants applying to remain in the UK.

Older migrants may also be indirectly impacted by the increase to the Health Charge due to the lower average earnings. Statistics from the OECD highlight that the mean average earnings among individuals aged 55 or over was generally between 2.2% and 13% lower than the prime age category, however in some instances such as Norway (10.7% higher) the average wage for individuals who are aged 55 or over is higher than the average wage for individuals in the prime age category.

Although older migrants may have lower average earnings with which to afford the Health Charge, they are also likely to use the NHS more intensively than younger migrants and provide a higher cost burden to the NHS. The Health Charge is set at a fixed rate which does not take account of the usage an individual makes of the NHS, therefore migrants who are proportionally more likely to use the NHS at a greater intensity will receive greater value for money.

Home Office analysis suggests that the impact on older people is likely to be minimal, with only around 1% of IHS eligible applications made by those over the age of 65 in the year ending March 2023. Older people who do not have the disposable income to pay the Health Charge are less likely to be able to meet the requirements of the immigration routes affected.

Figure 5 – Median UK weekly wage differentiated by age range^{[footnote 10]}, 2022

Age	Median weekly pay
All employees	£640
16-17	£229
18-21	£402
22-29	£546
30-39	£678
40-49	£727
50-59	£681
60+	£603

While there may arguably be an indirect impact on migrants who are younger (18-30) or older (65+), the impact is deemed to be justified by the overarching policy objective of ensuring that migrants coming to or remaining in the UK contribute to the NHS through the Health Charge. The calculation of the Health Charge takes account of the age distribution of migrants on relevant visa routes and so the average amount of the Health Charge reflects the lower expected healthcare use (and costs) of migrants due to the younger average age of the cohort.

Neither the changes to formally exempt applications for the Ukraine Schemes and the Stateless immigration route from payment of the Health Charge nor changes to replace obsolete terminology are deemed to have an indirect impact on the protected characteristic of age.

Disability

Direct discrimination

No direct impacts have been identified for migrants sharing the protected characteristic of disability. The Health Charge is set at a fixed amount and is not differentiated on the basis of the usage a migrant makes of the NHS.

Neither the changes to formalise exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless applications nor the changes to replace obsolete terminology are deemed to impact on the protected characteristic of disability.

Indirect discrimination

There is evidence to suggest that individuals within the protected characteristic of disability are less likely to be working and more likely to earn less annually^{[footnote 11]} and therefore may be disproportionately affected by the increase to the Health Charge.

Statistics compiled by the Department for Work and Pensions indicated that for 2022, the disability employment rate in the UK was 52.6% compared to 82.5% for individuals who do not share the protected characteristic of Disability.^{[footnote 12]} The Disability employment gap was therefore 29.8%. Figure 6 below also highlights that the disability employment gap increases with age, with a higher percentage of older individuals sharing the protected characteristic of age being unemployed. This means there is a correlation between the protected characteristics of age and disability and therefore there is likely to be a higher impact on individuals who fall within the intersectionality of age and disability protected characteristics.

Figure 6 – Employment rates gap between age categories

Age	Disabled employment rate	Non-disabled employment rate
16-17	17%	22%
18-24	45%	64%
25-34	62%	89%
35-49	63%	91%
50-64	48%	80%

The disability employment gap is also significant for countries outside of the UK with the disparity between the percentage of individuals sharing the protected characteristic of disability of those who do not being significant. Figure 7 below highlights that for developed countries, the disability pay gap ranges between 16% (Switzerland) and 39% (USA) with an average disability employment gap of 27%, indicating that individuals sharing the protected characteristic of disability are less likely to be employed. The disparity between the disability employment gap is likely to be larger for developing countries. In countries without a developed social security framework, the disparity could be larger as there may be limited or no protection for individuals sharing the protected characteristic.

Figure 7 – Disability employment gap^{[footnote 13]}

	Employment rate for people with disability	Employment rate for people without disability
UK	51%	78%
Norway	43%	77%
Switzerland	58%	74%
Canada	53.5%	72.2%
Netherlands	46%	72%
Germany	42%	72%
US	32%	71%
Austria	44%	70%
OECD	44%	70%
France	45%	65%
Belgium	33%	65%
Spain	29%	62%
Italy	32%	60%

Additionally, research conducted by the Office for National Statistics (ONS) outlined that in the UK, individuals with the shared protected characteristic of disability will on average earn 13.8% less than individuals who do not share the protected characteristic.^{[footnote 14]}

Due to the combination of lower employment rates and lower earnings for individuals with the protected characteristic, it is likely that increasing the Health Charge may have a higher impact on migrants sharing the protected characteristic of disability. For those who earn less, it is likely that they would not meet the requirements of the immigration routes that require the Health Charge to be paid. Any additional impact is proportionate to the wider aims of the policy.

Some disabled people may use health services more intensively than other groups. However, the Health Charge is charged at a flat rate, not based on potential use of NHS services by an individual. People with disabilities may use the NHS more intensively and represent a higher cost burden for the NHS. Migrants within the protected characteristic of disability may receive proportionally better value for money due to the NHS care they receive. As the Health Charge paid is not differentiated on an individual’s usage, migrants who are in the protected characteristic of disability would likely pay less through the Health Charge than they would pay if charged for treatment directly.

The Home Office does not record data on whether applicants are within the protected characteristic of disability, as such there is no data available to highlight the proportion of applicants who may fall within the protected characteristic of disability.

Although increases to the Health Charge may indirectly impact on migrants in the protected characteristics of disability due to lower average earnings, the impact is deemed to be justified by the overarching policy objective of ensuring that migrants coming to or remaining in the UK contribute to the NHS through the Health Charge.

Neither the changes to formalise exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless applications nor the changes to replace obsolete terminology are deemed to have an indirect impact on the protected characteristic of disability.

Marriage and Civil Partnership

Direct discrimination

No direct impacts have been identified for persons sharing the protected characteristic of Marriage and Civil Partnership from the increase to the Health Charge.

Neither the changes to formalise exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless applications nor the changes to replace obsolete terminology are deemed to impact on the protected characteristic of Marriage or Civil Partnership.

Indirect discrimination

It is arguable that the increased Health Charge rates may have a higher impact on migrants who share the protected characteristic of Marriage and Civil Partnership. Migrants applying to enter or remain in the UK at the same time as a dependent partner will have an increased upfront burden of costs compared to migrants who do not share the protected characteristic.

The Health Charge is applied to individuals at a flat rate regardless of whether an individual shares the protected characteristic of Marriage and Civil Partnership or not. The Health Charge is paid by each individual applying to enter or remain in the UK, the amount of Health Charge which must be paid is based on the duration of immigration permission applied for rather than the marital status of the applicant.

Fee Waiver applications are available on certain Family and Human rights routes, they enable applicants to request a full or partial fee waiver. Applications for Fee Waivers are assessed on affordability which takes into account the overall cost of visa fees and Health Charge. The provision of Fee Waivers for Human Rights applications is necessitated by the European Convention on Human Rights and the Human Rights Act, Fee Waiver applications ensure the Home Office is compliant with convention rights. These waivers ensure that the department meets its international obligations including under Article 8 of the European Convention on Human Rights. Migrants with the protected characteristics of Marriage and Civil Partnership are potentially more likely to qualify for a fee waiver due to the overall cost of the visa fees and Health Charge.

Although the upfront cost implications for migrants with the shared protected characteristic of Marriage and Civil Partnership may provide a cost barrier, the impact is justified by the overarching policy objective of ensuring that migrants coming to or remaining in the UK contribute to the NHS through the Health Charge.

Neither the changes to formalise exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless applications nor the changes to replace obsolete terminology are deemed to have an indirect impact on the protected characteristic of Marriage and Civil Partnership.

Pregnancy and Maternity

Direct discrimination

No direct impacts on individuals sharing the protected characteristic of Pregnancy and Maternity have been identified. The Health Charge is applied at a flat rate, it is not differentiated based on pre-existing conditions.

Neither the changes to formalise exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless applications nor the changes to replace obsolete terminology are deemed to impact on the protected characteristic of Pregnancy and Maternity.

Indirect discrimination

Migrants with the shared protected characteristic of Pregnancy and Maternity may be indirectly impacted by the increase to the Health Charge. Individuals with the shared characteristic of Pregnancy and Maternity are likely to be on lower wages than individuals who do not share the characteristic.

In the UK, statutory maternity pay is set at 90% of an individual’s weekly wage for the first six weeks and whichever is lower of £172.48 or 90% of an individual’s weekly wage thereafter.^{[footnote 15]} Although statutory maternity pay is set at this level within the UK, this is a minimum requirement which employers can exceed.

Globally, maternity pay generally equates to a proportion of the full salary that an individual would receive. The level which maternity pay is set at differs dependent on country. Some countries require 100% of salaries to be paid throughout maternity leave. However, across countries surveyed the average percentage of salaries is usually significantly less.^{[footnote 16]} For example, in the USA there is no requirement for maternity leave to be paid.

The lower earnings for individuals with the protected characteristic of Pregnancy and Maternity is not solely predicated on the level of maternity pay, it can also be influenced by the statutory period of maternity leave offered. The minimum length of maternity leave provided also varies significantly, for example, some countries which require full salaries to be paid during maternity leave, have substantially shorter periods of statutory maternity leave than those countries which offer longer periods of maternity leave at reduced pay. For example, Germany offers 100% salary during maternity leave, however the minimum maternity period offered is 14 weeks. Optional maternity leave exceeding the statutory period is unpaid, therefore individuals sharing the protected characteristic of Pregnancy and Maternity are likely to have lower incomes throughout the statutory period as well as any additional period of further leave.

Therefore, migrants with the shared characteristic of Pregnancy and Maternity are likely to earn less, meaning that migrants sharing the protected characteristic are potentially less likely to be able to afford the increased Health Charge.

The Health Charge is paid at a flat rate which does not take account of individual usage. Migrants who are pregnant at the time of application are more likely to use the NHS during their immigration permission at a higher intensity than individuals who do not share the protected characteristic.

For example, for maternity treatment the cost is differentiated on the basis of duration and intensity of treatment, with the cost graded within six levels. The cost of the delivery phase is between £2,242 and £6,652 with antenatal costs being between £1,107 and £2,947 with post-natal costs of between £233 and £793. Therefore, maternity treatment will cost the NHS a minimum of £3,582 with the highest cost delivery combined with intensive ante-natal and post-natal care coming to £10,392.^{[footnote 17]} The cost to the NHS of providing maternity services equates to a total which exceeds the cost of the Health Charge.

The Health Charge is set at a flat rate regardless of the usage an individual migrant makes of the NHS, whereas the cost of private medical insurance is differentiated where an individual has pre-existing health conditions, additionally certain healthcare such as maternity are not always covered under private health insurance. The Health Charge provides applicants with comprehensive access to the NHS for the duration of their stay, it does not impose further charges for maternity care.

Therefore, migrants with the shared protected characteristic of pregnancy and maternity are likely to get better value from the Health Charge than migrants who do not share the protected characteristic.

Since August 2017 NHS-funded assisted conception services in England are not free of charge to people who have paid the Health Charge unless another exemption applies in the Charging Regulations.

Neither the changes to formalise exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless applications nor the changes to replace obsolete terminology are deemed to indirectly impact on the protected characteristic of Pregnancy and Maternity.

Race

Direct discrimination

The Immigration (Health Charge) Order 2015 will provide an express authorisation for caseworkers to apply an exemption from the Health Charge to applications made under Appendix Ukraine Scheme. The exemption from charge will predominately put Ukrainian nationals in a more favourable position than others, although non-Ukrainian family members of certain Ukrainian nationals are able to apply under the Appendix in certain circumstances. The exemption from payment of the Health Charge supports a proportionate means of achieving the legitimate aim of supporting individuals displaced by the Russian invasion of Ukraine. The exemption from payment of the Health Charge supports the broader humanitarian response to the invasion of Ukraine, in line with the statement the Home Secretary made on 1 March 2022.^{[footnote 18]}

No direct impacts for migrants sharing the protected characteristics of Race have been identified from increasing the Health Charge or updating obsolete terminology.

Indirect discrimination

As highlighted in Table 1 through 3 above, entry clearance and extensions visas to the UK are predominantly composed of a relatively small number of nationalities with India, China, Pakistan, Nigeria and the Philippines contributing a significant percentage of applications. For Sponsored study applications, the top five nationalities in the year ending June 2023 (India, China, Nigeria, USA and Pakistan) account for 73.3% of all entry clearance grants. Due to the high volumes of applications from these countries, a higher amount of applicants overall from these countries are likely to be impacted by the increased Health Charge compared to nationals from other comparator groups where the amount of visas granted or extended are lower in number. However, the Health Charge is not differentiated based on an individual’s race, the Health Charge is a set rate which applies equally to each individual within those groups, regardless of Race.

Although there is the possibility that migrants may be indirectly affected by the increase to the Health Charge, the Health Charge increase is a proportionate means of achieving the legitimate aim of ensuring that migrants, regardless of their Race, pay the Health Charge at a rate which covers the cost to the NHS derived from treating Health Charge payers.

Neither the changes to formalise exemptions from payment of the Health Charge for the Stateless applications nor the changes to replace obsolete terminology are deemed to indirectly impact on the protected characteristic of Race.

Religion or Belief

Direct discrimination

No direct impacts for migrants sharing the protected characteristics of Religion or Belief have been identified from increasing the Health Charge.

Neither the changes to formalise exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless applications nor the changes to replace obsolete terminology are deemed to impact on the protected characteristic of Religion or Belief.

Indirect discrimination

As outlined in Table 1 through 3, the majority of grants of entry clearance and extensions of stay across work, study and family routes originate from Asia, with over 50% of grants in each category. Due to the high proportion of entry clearance applications from the region, analysis of the religions followed in the region would determine any indirect impact. The countries with high volumes of UK visa applications do not have a single homogeneous religious population. For India, the population is predominantly Hindu, Muslim or Sikh and for China Buddhism and Folk Religion form the majority of religious belief.

The Home Office does not record data on the religion or belief that a migrant holds.

Due to the high volumes of applications from certain regions, there may be a higher number of applicants who practise a specific religion who are impacted by the increases to the Health Charge. However, the Health Charge is applied at a flat rate regardless of the Religion or Belief that is followed by a visa applicant. The potential higher impact on migrants who practice a specific Religion or Belief is proportionate to achieving a legitimate aim of ensuring migrants granted immigration permission do not place a burden on the NHS by setting the Health Charge at a level which covers the average cost to the NHS of treating Health Charge payers.

The exemption from payment of the Health Charge for the Ukraine Schemes may have an indirect impact on the basis of Religion. The population of Ukraine are predominantly Christian with a significant portion of the population following Orthodox Christianity. Information from the Encyclopaedia Britannica^{[footnote 19]} for 2004 suggested that 46% of the population of Ukraine followed Christian Orthodox Religion whereas for 2018 World Atlas stipulates that 65.4% of the population follow Christian Orthodox religion.^{[footnote 20]} Therefore, the Ukraine Schemes being exempt from payment of the Health Charge means migrants who follow Orthodox Christianity are likely to be positively impacted by the exemption.

Neither the changes to formalise exemptions from payment of the Health Charge for Stateless applications nor the changes to replace obsolete terminology are deemed to indirectly impact on the protected characteristic of Religion or Belief.

Sex

Direct discrimination

No direct impacts for migrants sharing the protected characteristics of Sex have been identified from increasing the Health Charge.

Neither the changes to formalise exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless applications nor the changes to replace obsolete terminology are deemed to impact on the protected characteristic of Sex.

Indirect discrimination

As per Figure 2, the demographics of Health Charge payers are fairly evenly split between females and males, with 51% of Health Charge payers being male and 49% being female. The Sex breakdown for Health Charge payers suggests that there is no impact on Sex caused by the Health Charge.

However, the overarching figures may somewhat mask any potential impact on the protected characteristic of Sex. The statistics for Health Charge payers will include all applications, including dependents, a higher proportion of dependents are potentially likely to be Female, due to the prevalence of gender roles in other countries. Evidence suggests that, in general women earn less than men^{[footnote 21]}, this disparity can be more prevalent in other countries. The Global Gender Gap Report^{[footnote 22]} by the World Economic Forum highlight that the gender pay gap has closed, however on average females earn 68.1% of what males earn. For example, Pakistan is ranked at 145 of 146 with Females earning 56.4% of what Males earn and India is ranked at 135 with Females earning 62.9% of what Males earn.

Due to the disparity caused by gender pay gaps, it is therefore possible that increases to the Health Charge will disproportionately impact on Females, due to the relative pay which Females earn in comparison to Males. However, we consider this proposal to be a proportionate means of achieving the legitimate aim of ensuring that temporary migrants make a fair and proportionate contribution to the NHS. The calculation of the Health Charge takes account of the sex breakdown of migrants on relevant visa routes and so the average amount of the Charge reflects the differences in costs of care for males and females.

Neither the changes to formalise exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless applications nor the changes to replace obsolete terminology are deemed to have an indirect impact on the protected characteristic of Sex.

Sexual Orientation and Gender Reassignment

Direct discrimination

No direct impacts have been identified for persons sharing the protected characteristics of Sexual Orientation or Gender Reassignment from the increase to the Health Charge.

Neither the changes to formalise exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless applications nor the changes to replace obsolete terminology are deemed to impact on the protected characteristics of Sexual Orientation or Gender Reassignment.

Indirect discrimination

No impacts have been identified for persons sharing the protected characteristics of Sexual Orientation or Gender Reassignment from the increase to the Health Charge.

Neither the changes to formalise exemptions from payment of the Health Charge for the Ukraine Schemes and Stateless applications nor the changes to replace obsolete terminology are deemed to have an indirect impact on the protected characteristics of Sexual Orientation or Gender Reassignment.

3b. Consideration of limb 2: Advance equality of opportunity between people who share a protected characteristic and people who do not share it.

Due regard has been given to the need to advance equality of opportunity between those who share a protected characteristic and those who do not. Given the proposed Health Charge increases will be applied equally to all Health Charge payers, individuals with a protected characteristic vs those that do not are unlikely to face significant inequality of opportunity resulting from the proposals.

Furthermore, any minor impact would be justified by the proportionate nature of the proposals as a means of ensuring that the Health Charge covers the cost to the NHS of providing treatment to Health Charge payers in order to ensure a cost burden is not placed on the NHS.

The disability and sex pay gaps referenced in limb 1 of this assessment have relevance to advancing equality of opportunity between people who share a protected characteristic and people who don’t. With women and disabled people more likely to earn less than men and non-disabled people, the proposed Health Charge increases arguably have a potential minor negative impact on advancing equality of opportunity between people who share a protected characteristic and people who do not share it. This is because women and disabled people may be more likely to be impacted by the proposed increases to the Health Charge because they are more likely to have less disposable income.

However, the Health Charge is set at a fixed amount for each applicant, based on the average annual cost to the NHS of treating Health Charge payers. Those who pay the charge can access the full range of NHS services in generally the same manner as a permanent resident. The Health Charge is set as an average amount and does not vary with an individual’s usage (or likely use) of the NHS, which is likely to benefit those who need to use the NHS more than average, many of whom will have protected characteristics (e.g. pregnancy, disability, age). Therefore, although migrants who share the protected characteristics of disability and pregnancy and maternity are likely to be impacted by the proposed increases to the Health Charge due to lower average incomes, migrants sharing these characteristics are likely to use the NHS more intensively and therefore receive better value from the Health Charge. As sex and pregnancy and maternity are interlinked, this also reduces the impact on the protected characteristic of sex.

3c. Consideration of limb 3: Foster good relations between people who share a protected characteristic and persons who do not share it.

The Equality Act 2010 states that having due regard to the need to foster good relations involves having due regard, in particular, to the need to tackle prejudice and promote understanding between people who share a protected characteristic and those who do not.

As set out above, the Health Charge is set at a fixed rate for migrants. This benefits those who may use the NHS more than average, and ensures they are able to access the healthcare they need for the duration of their visa. The Home Office informs the NHS in England of those who have paid the Health Charge, thereby ensuring they can easily be identified at the point of accessing care.

It is considered that overall the proposed increases to the Health Charge do not adversely affect good relations between people who share certain protected characteristics and those who do not.

4. Considerations in line with the Secretary of State’s duty under Section 55 of the Borders, Citizenship and Immigration Act 2009

Section 55 of the Borders, Citizenship and Immigration Act 2009 requires the Secretary of State for the Home Department to ensure that due regard is paid to the need to safeguard and promote the welfare of children in the UK when exercising immigration and nationality functions.

Turning first to the category of work and study visas, while it may be argued that Health Charge increases may deter individuals from entering or extending their stay in the UK, it is not considered that such a factor can be said to have a particular impact on the welfare of children, whose parents or relatives (with whom they would typically apply as a dependent) can make alternative choices about where to pursue those purposes. Furthermore, the policy intention behind the Health Charge and these proposed increases, is that the cost to the NHS of treating Health Charge payers is fully covered by those who pay the Health Charge.

Regarding the Health Charge paid for rights-based applications, stakeholders have raised concerns regarding the impact that Health Charge levels can have on the welfare of children. This includes the impact that the Health Charge and visa fees in conjunction may have on the ability of children to access limited leave to remain or qualify for indefinite leave to remain due to the cost burden placed on applicants, particularly in cases where those individuals may have been born in the UK, arrived in the UK at an early stage or spent a substantial part of their life here. In cases where there are challenges around access, it is reasonable to conclude that there may consequently be potential impacts on that child’s welfare as a result of being unable to secure the benefits associated with that status. In terms of mitigations for these potential impacts, the department offers affordability-based fee waivers for Family and Human rights applications as well as exemptions from payment of the Health Charge for certain protection cohorts.

Applications for Fee Waivers are assessed on affordability which takes into account the overall cost of visa fees and Health Charge. The provision of Fee Waiver for Human Rights applications is necessitated by the European Convention on Human Rights and the Human Rights Act, Fee Waiver applications ensure the Home Office is compliant with convention rights. These waivers ensure that the department meets its international obligations including under Article 8 of the European Convention on Human Rights.

5. Summary of foreseeable impacts of policy proposal, guidance or operational activity on people who share protected characteristics

Age

Potential for Positive or Negative Impact?

Positive/ Negative

Explanation

The increased rates of Health Charge may indirectly impact on migrants who are younger (18-30) and migrants who are older (65+) due to the comparatively lower earnings for these groups than the prime age range.

Action to address negative impact

The Health Charge includes a discounted rate for students, their dependents, applicants for the Youth Mobility Scheme and children under the age of 18. The discounted rate applies to these cohorts due to the lower cost of providing treatment to children and the lower earnings potential for younger individuals. Older migrants (65+) represent around 1% of total migrants due to visa requirements, as such mitigating action would not be proportionate.

Disability

Potential for Positive or Negative Impact?

Positive/ Negative

Explanation

Individuals in the protected characteristic of disability on average have lower earning potential than individuals who do not share the protected characteristic, therefore increases to the Health Charge may have a more significant impact on affordability for migrants who are disabled.

However, the Health Charge is charged at a set rate and having paid the Health Charge, migrants are able to access the NHS on broadly the same basis as UK nationals. As the Health Charge does not take account of the individual usage, migrants with underlying conditions necessitating more treatment (e.g., disability) are likely to receive better value for money than migrants who do not have underlying conditions.

Action to address negative impact

No action

Gender Reassignment

Potential for Positive or Negative Impact?

N/A

Explanation

No impacts have been identified for persons sharing the protected characteristic of Gender Reassignment.

Action to address negative impact

No action

Marriage and Civil Partnership

Potential for Positive or Negative Impact?

Negative

Explanation

Individuals who share the protected characteristic of Marriage and Civil Partnership may be impacted more than those who don’t by the increase. Where migrants apply at the same point as their partner, the combined Health Charge may require a higher financial outlay than migrants who do not share the characteristic.

Action to address negative impact

Fee Waiver applications are available for migrants on specific Family and Human Rights immigration routes. Fee Waiver applications are based on affordability, therefore where partners are applying together on these routes, the Fee Waiver can mitigate the cost of the Health Charge.

Pregnancy and Maternity

Potential for Positive or Negative Impact?

Positive/ Negative

Explanation

The Health Charge is set at a fixed rate which doesn’t take account of the usage an individual makes of the NHS, as such migrants with pre-existing conditions who are likely to require NHS treatment may receive better value for money. Migrants sharing the characteristic of Pregnancy or Maternity would be more likely to access NHS treatment than migrants who do not share the protected characteristic. Additionally, the cost of maternity treatment provided by the NHS generally will exceed the cost paid for the Health Charge.

Action to address negative impact

No action

Race

Potential for Positive or Negative Impact?

Negative

Explanation

A significant proportion of applications for visas are made from nationals of a small number of countries, as such it is possible that increases to the Health Charge may impact certain nationalities to a greater extent than others due to the volume of applications. Additionally, the average annual salary in developing countries is considerably lower than the average salary within the UK, as such the increase to the Health Charge may place a higher economic burden on migrants who hold a shared protected characteristic of Race.

Action to address negative impact

No action.

Religion or Belief

Potential for Positive or Negative Impact?

Negative

Explanation

A significant proportion of applications for visas are made from nationals of a small number of countries, as such it is possible that increases to the Health Charge may disproportionally impact on migrants who practice certain Religions or Beliefs.

Action to address negative impact

No action

Sex

Potential for Positive or Negative Impact?

Negative

Explanation

The Gender pay gap in place in each country may mean that increases to the Health Charge may have a higher impact on women than men. The Health Charge may become unaffordable for women in comparison to men.

Action to address negative impact

No action

Sexual Orientation

Potential for Positive or Negative Impact?

N/A

Explanation

No impacts have been identified for persons sharing the protected characteristic of Sexual Orientation from the increase to the Health Charge.

Action to address negative impact

No action

6. In light of the overall policy objective, are there any ways to avoid or mitigate any of the negative impacts that you have identified above?

The Health Charge includes a discounted rate for students, their dependents, applicants for the Youth Mobility Scheme and children under 18. The lower rate for children reflects the lower costs to the NHS of treating children. Additionally, the discounted rate for students and applicants for the Youth Mobility Scheme is likely to apply to younger migrants, reflecting the lower earning potential which these cohorts may have. The discounted rate provides a mitigation for younger applicants within the protected characteristic of age. Older migrants make up less than 1% of the total volume of Health Charge payers, as such mitigation action is not deemed proportionate for this cohort.

Where persons applying to extend their stay on the basis of their right to family life are destitute and unable to afford the cost of applying to remain, the Home Office already operates a fee waiver policy. We will keep the fee waiver policy and process under review to ensure that it allows sufficient mitigation of the amount payable in these circumstances.

7. Review date: August 2024

8. Declaration

I have read the available evidence and I am satisfied that this demonstrates compliance, where relevant, with Section 149 of the Equality Act and that due regard has been made to the need to: eliminate unlawful discrimination; advance equality of opportunity; and foster good relations.

SCS sign off: Rebecca Nugent

Name/Title: Rebecca Nugent

Directorate/Unit: (Compliant Environment and Enforcement Unit)

Lead contact: Laurence Brammer

Date: July 2023

For monitoring purposes all completed EIA documents and updated EIAs must be sent to the PSED@homeoffice.gov.uk

Date sent to PSED Team: 25 September 2023

1. Migration statistics - GOV.UK (www.gov.uk) ↩

2. Visa volumes include visa types which would not be liable to pay the Health Charge, specifically in work routes the Health and Care Worker visa contributes significant volumes to the overall volumes of workers, however this cohort are exempt from payment of the Health Charge. ↩

3. https://www.gov.uk/government/collections/migration-statistics ↩

4. https://gp-patient.co.uk/analysistool?trend=0&nationaldata=1 ↩

5. https://www.england.nhs.uk/publication/technical-guide-to-allocation-formulae-and-convergence-for-2023-24-to-2024-25-revenue-allocations/ ↩

6. https://digital.nhs.uk/data-and-information/publications/statistical/hospital-admitted-patient-care-activity/2022-23/summary-reports-copy ↩

7. https://www.england.nhs.uk/publication/2023-25-nhs-payment-scheme/ ↩

8. https://stats.oecd.org/Index.aspx?DataSetCode=AGE_GAP ↩

9. https://migrationobservatory.ox.ac.uk/resources/briefings/migrants-in-the-uk-labour-market-an-overview/ ↩

10. https://commonslibrary.parliament.uk/research-briefings/cbp-8456/ ↩

11. http://www.npi.org.uk/files/7814/0490/1005/Disability_long_term_conditions_and_poverty.pdf ↩

12. https://www.gov.uk/government/statistics/the-employment-of-disabled-people-2022/employment-of-disabled-people-2022 ↩

13. https://www.oecd.org/social/disability-work-and-inclusion-1eaa5e9c-en.htm ↩

14. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/disability/articles/disabilitypaygapsintheuk/2021#:~:text=In%202021%2C%20the%20disability%20pay,of%20%C2%A314.03%20per%20hour. ↩

15. https://www.gov.uk/maternity-pay-leave/pay ↩

16. https://worldpopulationreview.com/country-rankings/maternity-leave-by-country ↩

17. https://www.england.nhs.uk/publication/2023-25-nhs-payment-scheme/ ↩

18. https://www.gov.uk/government/speeches/home-secretary-statement-on-humanitarian-support-for-ukrainians ↩

19. https://www.britannica.com/place/Ukraine/Languages ↩

20. https://www.worldatlas.com/articles/largest-religions-in-the-ukraine.html ↩

21. https://www.gov.uk/government/publications/dhsc-gender-pay-gap-report-and-data-2022/2022-gender-pay-gap-report ↩

22. https://www.weforum.org/reports/global-gender-gap-report-2022/digest ↩