Introduction
Adult Dependent Relative Rules (ADR)
The innate right of settled migrants, including those providing vital services in the health and care sectors, to care for their elderly parents in a familial setting has been hampered by the Government’s Adult Dependent Relative Rules.
The current ADR rules and the impact of their enforcement on families and children and grandchildren was forcefully described by the Joint Council for the Welfare of Immigrants (JCWI) Report (2014) as “Harsh, Unjust, and Unnecessary”. The current criteria is very prescriptive and limits any reasonable chance of successful applications as the Rules and their interpretation stipulate the elderly person must demonstrate that s/he “requires long-term personal care to perform everyday tasks; and be unable to obtain the required level of care in the country where they are living, ” an extremely insuperable threshold upheld by the Court of Appeal in Britcits v Secretary of State for the Home Department [2017] EWCA Civ 368
As a consequence, families have been deliberately fragmented and segregated for many years, and many key workers, (including doctors and health care professionals) have had to make multiple annual journeys, whenever their parents, or a surviving parent falls ill, causing much disruption to their patient/client groups and work teams.
A significant number of essential health professionals have abandoned careers here when the filial importance of caring for their parent became the priority, and as they do not want to abandon a parent to care or housing or social help which is often unregulated, non- accredited and unreliable.
As a senior Court of Appeal Judge noted in a previous landmark case:
“The availability of medical care (public or private) is no substitute for the ordinary expectation that an elderly and ailing parent would be looked after by his family, and that the ability to do that was an important part of family life for both the carers and the cared-for.”
It is not about the adequacy of care alone, but also the importance and relevance of bonded support and care from the children and grandchildren, and such care should be seen as alleviating the loneliness, lack of dignity and lack of purpose felt by those parents abandoned to institutional care.
When he was Health Secretary, Jeremy Hunt opined that “loneliness and isolation” among the elderly is “something that we actually want to do something about”, and that entering old age “should not involve waving goodbye to one’s dignity” (at the National Children and Adults Services (NCAS) conference in 2013).
Applying that objective humanely to all families would mean that no elderly parent is made vulnerable, and UK law does not discriminate against migrants or many British citizens in relation to the right to safeguard, and provide such care to an older parent.
A leading psycho-geriatrician, Dr Junaid, has noted that research shows that depression and morbidity are decreased by such familial care, stating:
“Families provide essential financial, practical and emotional support. When children are abroad, in addition to the social isolation, it is much more difficult to put in place practical help and support. It is possible to make the argument that those left behind are in greatest need of support.”
During the Covid-19 pandemic, the non-viability of travel has brought the needs of an elderly parent abroad into focus. Their adult children here face the prospect of being unable to provide care for their elderly parent within a home setting, especially if they become ill. These children are also unable to be sensitive to carry the terminal wishes and needs of the parent and are also unable to perform post death rites.
This Government is asked to commit now to the immediate reform of the ADR rules and policy, and to ensure that the stringencies of its interpretation are removed by urgent legislation, to ensure a family care centered approach for the reunification of settled migrants and their elderly parents.
British Association of Physicians of Indian Origin (BAPIO) and Association of Pakistani Physicians of Northern Europe. (APPNE) have joined hands to take up this humanitarian issue for a campaign.
Update
Dear All,
Since we wrote to you in January, we wanted to update you on the work underway on the issue of deserving elderly parents under Adult Dependent Relative (ADR) rules.
We wrote a joint letter to the home secretary with APPNE, BMA and four Royal colleges.
The response received from the Immigration minister has been disappointing but not unexpected and we know that this will need to be a sustained campaign.
We have secured the support of the Labour shadow cabinet, are in discussion with the chair of the All-Party parliamentary group on immigration and law and other political parties. We continue to pursue this, and we are hopeful of further support over the coming weeks.
The issue has been covered in national media e.g., inews which is running a series of articles on the issue, BBC Radio, RT UK news and Eastern Eye further covered here and elsewhere.
We have gained support from many prominent names in the field along with over 300 doctors in this letter
The issue has been covered in the medical media e.g., BMJ, Doctor and Pulse and Indian national media e.g., Aaj Tak and Times of India. You can also hear more in the sound cast here.
Members of the working group continue to participate in the media programmes in the UK to increase awareness of the issue and its impact on the NHS.
We have collated heart-wrenching case stories of many colleagues affected adversely by these rules led by our legal lead and Barrister Ms Usha Sood.
We have also collated testimonies from many who have already left the NHS and UK due to these rules.
Along with our partner organisations, we are working on securing wider support from nursing colleagues, other royal colleges and like-minded organisations such as Unison, BDA etc.
We are also working with experts around demolishing the misleading argument of economic burden on UK taxpayers if rules were to be changed as it is overstated and ignores the losses to the taxpayer of losing senior clinicians.
We also want to say thank you to so many of you for writing to your MPs. We know that majority of the responses received have been generic and have failed to directly address the issue. However, the political pressure must continue.
Hence, we humbly ask you to:
- Respond to your MP with the template letter attached here
- Promote the relevant material on social media and within your networks. You can follow the progress on twitter @ADRcampaign
This is a journey, and the momentum is building. We must not lose hope as our ask is fair, just and the right thing to do. This cannot be achieved without your support.
For more information or if you are happy to share your own story, please write to admin@bapio.co.uk
Grateful thanks
BAPIO ADR group Dated 17.03.21
Drs Raman Lakshman, Achuthan Sajayan, Kamal Sidhu and Baxi Neeraj Sinha.
ADR Brief to Media
ADR Brief for Media
This House is fully aware that the pandemic has reminded us of the value and need of family. A significant number of settled migrants in the healthcare workforce have been stressed and are at high risk of burnout from the consequences of the Adult Dependent Relative visa which separate them from their elderly and frail parents and require care to be by multiple trips or offered remotely. As the PM has said, being able to hug one’s loved ones and care for them is our goal for all in this country.
Not so for a large number of the NHS workforce. The 2012 Adult Dependent Relative visa rules make it almost impossible for British citizens and those settled in Britain to bring their elderly and frail parents and on their own overseas to join them here. The last Home Office review of the Rules showed that applications had fallen from about 2000 to just 162 applications in 2016. The emotional impact on these families has often been for the parents to fall ill and die alone due to these draconian Rules.
A survey of nearly one thousand doctors carried out in August 2020 by the Association of Pakistani Physicians of Northern Europe (APPNE) and the British Association of Physicians of Indian Origin (BAPIO) found that over 90% of them reported feelings of anxiety, stress and helplessness due to this issue. What is even more worrying is that 8 out of 10 are thinking of relocating due to the Rules and only 1 out of 10 respondents felt that they had adequate support from their employer over trips abroad, necessitated by their parent’s illness or emergencies. This adds to the burnout and attrition of the health and care sectors. General Medical Council (GMC) figures suggest that since 2015 more than 2,000 GPs and specialists have left for another country and asked to be erased from the UK register. More than 4,000 non-specialists, such as junior doctors, have quit their jobs and moved abroad. Many have attributed their move to the ADR Rules.
The situation of separation from elderly parents has caused huge distress and anxiety for health and care staff and affected their day-to-day productivity as well as disruption to their service to their patients when called away.
Is it not time to review the ADR visa rules so that they are applied humanely? Elderly and frail parents who are struggling overseas can and should be looked after by their settled families here as in many other comparable nations?
The Home Office must move from their standard response that these rules are necessary to look after the rights of the taxpayer, but these were never properly considered.
It is time to readdress the economic fallacy. Any such costs are also outweighed by the cost of trained health professionals leaving the country at this difficult time, and by the contribution of settled migrants to our communities.
BAPIO 11 May 2021
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Strategy Committee
Dr Raman Lakshman
Dr Achuthan Sajayan
Dr Kamal Sidhu
Dr Baxi Neeraj Sinha
Case Study
These are documented cases of tragic separation of elderly parents and migrant children reflecting the historic injustice of the ADR Rules
Case Summary A (Mr AK & Mrs NK) (ongoing)
The Applicants are the elderly parents (in their early and late 80’s) of a front-line NHS Consultant, Dr AK, a British citizen. They recently came to visit AK in the UK after over an absence of two years during which he could not visit for work reasons. On meeting them at the airport, he was shocked to discover the physical and mental decline that had occurred since he last saw them in 2019. His father was showing early signs of dementia and Alzheimer’s disease. His mother had lost weight and could barely walk unassisted, and has had many falls. They were reluctant to tell their son and burden him about their problems, even though they have no one to support them in the home country, India.
As their only son, Dr AK has now decided to take responsibility and make an application for them to remain in the UK under his care. There is no family member who can look after them back home. Care homes and residential care in India have a reputation of being unreliable and unsafe, and are neither regulated or accountable. Having lived in the UK for over 20 years, and due to the highly demanding and important nature of his job, he cannot just give up his career and dedication to his patient community here to relocate to his former country country.
Dr AK hopes that the Home Office will exercise compassion and grant his parents a legal right to remain in the UK, so he can continue his work with the NHS without stress or disruption.
Case Summary B (Mr SK & Mrs SK)
These Applicants are the elderly Indian parents (now in their mid and late 80’s) of two British siblings, both senior health professionals (working as a highly senior surgeon in a unique field, and dentist for the NHS) and present here for over 30 years. Due to their age and poor health, their parents’ health had been declining rapidly.
The father suffered from diabetes, back problems, and high blood pressure. Both of them had become frailer and had difficulty walking around unaided. The mother had been diagnosed with advanced dementia and was very forgetful, often failing to remember to take important medication and not recognising family members. There was no one back home in India within 200 miles who could look after them. Repeated attempts were made to find suitable care in India, and the parents were finally accommodated in a care facility, advertised as state of the art facility with an on-site canteen, and 24-hour security. After the parents had been there for some months, their daughter made a welfare visit to find that she was able to walk in as there was no one at reception, that the canteen had not been implemented, and her father had to walk up and down three flights as the lifts often broke down. On one occasion, on his return his wife did not open the door foe a few hours.
They decided to apply for leave to remain in the UK to remain with and be looked after by their two children, and to be with their grandchildren who adored their grandparents.
Their application was first refused by the Home Office before their subsequent appeal was dismissed by an immigration judge. After a long and distressing legal battle (involving the tribunals and a High Court judicial review) spanning 4 years, they were eventually granted leave to remain in the UK.
Case Summary C (Mrs GG) (ongoing)
The Applicant is the elderly mother (in her late 60s) of her only child, a daughter who was in the UK with her British husband, and studying for a PhD. Mrs GG had been widowed suddenly, and was suffering from various health conditions including diabetes, cataracts, and depression, as well as cognitive deficit. She had also become very vulnerable to financial harassment and exploitation. Due to her deceased husband’s social and business standing in India, they had endured several extortion attempts which carried on even after his passing. Through fear of her safety back home, and due to her increasing dependency on her daughter, who was pregnant at the time, she applied to extend her stay in this country. The Applicant’s daughter was able to provide a supportive and loving environment in which physical and emotional support, and safeguarding, was readily available. Despite these difficult health circumstances, she was still required to attend regular appointments at an immigration reporting centre. Her application was refused by the Home Office. Shortly afterwards, her daughter gave birth through emergency C-section with life changing consequences. The child’s visual impairment, physical growth, and motor skills were affected. Over the next few months the Applicant became integral to her grandchild’s daily routine, involving physiotherapy, emotional support, and general household support which reduced the burden on her daughter and son-in-law. Despite her own difficulties, and this crucial change in circumstances for the family, the Home Office maintained their refusal of her application.
Her legal battle to remain with her daughter and grandchild and wider family is ongoing.
Case Summary D (Mrs VR)
The Applicant (an elderly mother in her 90’s) was a South Indian widow who was in her younger years a famous Carnatic classical radio singer. Her only two children (daughters) are British citizens working as senior NHS Consultants in the UK. The children and grandchildren have had limited contact with VR and her husband on their visits. VR had lived in India her entire life, and was married for over 60 years. She became her husband’s main carer for almost 2 decades as his health failed, until his death. His passing left her without the companionship and support she had enjoyed for so long. She slowly grew anxious about living alone and continued to struggle with her own health problems including: rheumatoid arthritis, high blood pressure, hypertension, cognitive issues and lack of self-worth. She was on several medications. Her children in the UK moved her to a more suitable accommodation, but quickly realised the need for a more permanent solution to her care needs. They did extensive research upon deciding to place her in a care home, but came to learn that in her home country care homes are unregulated and nurses work without any accreditation. The lack of health accreditation and of building safety regulations would still have left her at risk. The decision was made to make an application for her to remain in the UK. This application was supported by all of the family, most of whom were working as senior medical professionals, and was supported by her adult grandchildren who rotated to visit her frequently once she arrived. She was also able to hold her first great grandchild after birth.
This application was refused by the Home Office who accepted that her quality of life, at 90 years of age, would be more detrimental to her health in her home country than in the UK, but relied on the availability of some friends and one niece abroad in their refusal. Ultimately, upon appeal of the decision to the Immigration Tribunal, she insisted on attending her hearing, despite a psycho-geriatrician’s report that she lacked cognitive capacity to give evidence.
She spontaneously asked to address the court at the end of the hearing, and mesmerised the Judge in her impeccable and eloquent English by making an impassioned plea to remain, saying:
“I grew up in Colonial India. After the British have remained in my country for so long, what harm will come from letting me stay for the few remaining years I have with those I love and who love me“.
Her appeal was allowed and she was permitted to remain in the UK.
Case Summary E (Mr GM)
The Applicant is the elderly father (in his 70’s) of two British citizens. He came to the UK to spend time with his British sons following his wife’s death in Pakistan having been found wondering alone in a disoriented state by a passer by. They had been married for over 40 years. (Their only daughter had long since left to be with her own in laws and family). Over a period of 4 years he made several trips back and forth before the family came to terms with the fact that his bereavement was still raw, and his physical and psychological health was in major and irreversible decline. His eldest son and daughter-in-law had his dependencies assessed, and made an application for him to remain in the UK under their care. By this stage he had been diagnosed with Parkinson’s disease and dementia. He also suffered from depression, reduced mobility, and incontinence, and he would say “I just want only my sons to change my pads and clean me and help me kneel for prayers”. (On more than one occasion, his incontinence meant that his son had to take him back home on his way to Masjid, due to religious requirements for cleanliness). Despite his physical condition, only his grandchildren seem to motivate him to eat, exercise and smile.
The Home Office refused his application on the basis that (a) his daughter could assume full-time responsibility for his care and (b) his son could relocate to Pakistan to provide the same. Ultimately, he went on to successfully appeal the decision (however he was bedridden by the hearing and unable to attend in person.
(The legal battle by GM to remain in the UK with his family took over 3 years).
Case Summary F (Mr SJ & Mrs SQ) (ongoing)
The Applicants, from Pakistan, are the elderly parents of a British citizen living in the UK (they are in their mid 80’s and early 70’s). All their children are abroad, mainly in the UK. Their deteriorating mental and physical health has left them both wheelchair-bound, and completely dependent on the care of their son and daughter-in-law. This includes everything from helping them safely get to the bathroom to making sure they take their various medications at the correct times. Neither of them can stand for longer than a few minutes, and both require the use of a stair lift to reach the bedroom. Their son, and his family (especially grandchildren) make them want to get out of bed and try and have a daily routine. Islamic cultural norms dictate that children should provide their parents with care and support in old age. The other siblings and their children also visit most weeks, and all contribute to their private health care.
Repeated attempts to regularise their stay in the UK have been denied by the Home Office for over 6 years. Their carer son, after providing continuous care for them during their tenure in the UK, knows that their reliance on him is the only chance they have of the latter stages of their lives.
When checking for care homes in Pakistan, the family found that they are unregulated and unsafe, and even segregate the couple into separate male and female quarters. Being in a care-home in Pakistan would undoubtedly be detrimental to their physical and emotional health.
They hope that with their latest application the Home Office will exercise compassion and grant them the legal right to remain in the UK under their son’s care.
Case Summary G (Mr PC & Mrs SC) (ongoing)
The Applicants are the elderly (in their mid and early 70’s) parents of their British daughter who has lived in the UK for over 20 years. They came here on visitor visas after years of physical and mental abuse at the hands of their daughter in law in Tanzania, which their British daughter observed on a visit (including being restricted as to food, and confined to their room). Their son told his sister that if she was so concerned she should “take them and look after them.”
Their daughter then arranged for them to come and stay with her and her family in a safe and loving environment in the UK whilst attempting to resolve this family issue, but the son and daughter in law were adamant. Care homes in Kenya appeared to lack basic health and safety requirements, and were not compliant with any CQC standards.
Due to their declining health, and the continued risk to their welfare back home, they decided to take their daughter’s advice in applying for a legal right to remain in the UK beyond the expiry of their visa. The father is partially blind and also suffers from hypertension, high blood pressure, and intermittent blackouts. The mother has degenerative spinal issues. Upon examination of her condition, the consultant asked “how can any child leave their parent in this condition untreated?”
The Consultant made clear the need for an operation to relieve her pain. Ultimately, administrative errors resulted in the first two application attempts being returned. However, the third application was considered and refused by the Home Office on the basis that their conditions were not life-threatening; and that travel back to Tanzania would not have a ‘hugely detrimental effect’ on their conditions.
Their subsequent appeal was unsuccessful, but they have made a fresh application with more medical and other evidence of socio-dependency on their daughter.
Case Summary H (Mr LRP and Mrs LR )
Dr LR, a British citizen is the eldest son of these elderly Applicants (aged 87 and 78 ) and has had to deliver emergency and regular care to his parents for over 10 years. He has been supporting their day-to-day issues, medical emergencies, money issues, even flying over to India taking them to medical appointments, being there with them for hospital admissions and operations. His parents live by themselves in a 2 bedroom flat in Mumbai and do not have a supportive network or family or friends to look after them. So Dr LR has been the main carer for them, and in effect has been available 24/7 on call for them, making several unplanned trips when they need help. (His younger brother, who is based in the US has chronic fatigue and needs help himself, and their married sister, living 9 hours away, has her own family and in laws to care for).
Mr LRP has end stage renal disease (Stage 5 chronic kidney disease). Dialysis at his age and health would be a very big undertaking and so only viable option for management of his condition is palliative care.. He has severe hearing loss and even with hearing aid he cannot understand what doctors say to him so he must always be accompanied to appointments. The accumulation of toxins in his blood due to his kidney failure is affecting his ability to think, to carry out tasks, and makes him tired and sleepy. Over the last 6 to 12 months he has not been taking his medications in a timely way and not following the prescribed renal diet. He has a huge burden of treatment – he needs eye drops for glaucoma many times a day, has to take about 10 oral medications every day and also needs an injection once a week. He has had episodes of severe anxiety and crying and no one to support him through these. He has been the carer for Mrs LR, but over the last 12 months he has not been able to look after her properly as his own health has been severely compromised.
Mrs LR is very frail and cannot walk safely without support or a walking aid. She has severe osteoporosis and loss of muscle and has had a number of falls that have led to fractures of her spine, pelvis and forearms. She needs help for day to day activities – she cannot open a fridge or use a microwave, she does not cook, she does not leave the house, she cannot get up from the floor, she cannot pick things up from the floor, she cannot trim her nails. She needs food to be warmed and brought to her. She needs help with bathing and hygiene. She also has had chronic pain and a variety of symptoms and on psychiatric advice has been started on antidepressants. Her inability to leave the house and the further exacerbation of loneliness due to complete absence of any visitors due to the Covid pandemic has made her very withdrawn.
Dr LR, a Consultant Paediatrician with the NHS, realised on his emergency visit to India in November (which was another sudden, unplanned trip as his mother had fallen and become bedridden needing a urinary catheter) that anything short of 24/7 care would be inadequate. He had previously explored other options, like spending periods of time in India but was told by his Trust that this would not be workable for patients and the logistics of arranging such a job plan would be significant.
Alternative care provision in a home or with carers is not acceptable, as Dr LR will not abandon his parents to unregulated and unreliable care, and feels that he must carry out his filial duty, and allow his wife and the grandchildren to assist in that bonded and qualitative care.
He has now applied for his parents to remain in the UK.
Case Summary I ( Mr VGS and Mrs SVS)
The couple in their 60’scame early in the pandemic to visit their British daughter, a Obstetrics and Gynaecology trainee in the NHS. Their son in law is working as a Locum Consultant Paediatric Urologist, and has worked at acute units including Great Ormond Street Hospital. They have 2 children, aged 5 and 10.
The daughter (M) was working during the pandemic when she became unwell and was diagnosed with retroperitoneal cancer in May 2020. She had to undergo emergency, complex and major surgery and needed 3 weeks of hospital stay before discharge. She is currently undergoing adjuvant radiotherapy and is expected to need chemotherapy thereafter.
M is her parents only living child (her younger brother and only sibling died in childhood) and she has no other immediate family here. The presence of her parents is pivotal in the respite care of her children and in her fight against cancer with their emotional and psychological support. They have applied for leave to remain to allow them to be with the family during these extremely difficult times. As grandparents, they are not only providing essential bonded care and educational and cultural support to the grandchildren, but their presence also allows AU to continue to render his services as a Key Worker knowing that the family is being lovingly cared for.
Case Summary J
During the early pandemic, the NHS suffered an early devastating loss when Dr V R, a Consultant Paediatrician , passed away from Covid-19, aged only 48, having worked selflessly until he became ill. This was traumatic for his wife, L, herself a full time Consultant Pediatrician
The recently widowed L, was concerned for the immediate and long term-welfare of her daughter (K, a 6 year old), and the family’s care and viability going forward as she returned to work. She was finally able to get her elderly 74 year old mother, Mrs ZH to come over her home country in June 2020 on an emergency flight (organised with help from her Trust and L’s MP) for the bereavement rites, and respite help with the couple’s child.
Since her mother has been here, L and her daughter have become reliant on her regular and significant emotional and supportive care, and an application has been made for ZH to remain, with a copied request to the Prime Minister and Home Secretary for an expedited decision. Nothing has been heard.
L’s Trust has written to support the application for ZH to remain in strong terms: [W]e would completely support the application of Mrs Z H to remain in the UK to support her daughter and her granddaughter. Not only because her husband lost his life caring for children across the West Midlands, but also because it would allow many children in the [X] area to have the benefit of Dr L’s skills and dedication.”
It is to be hoped that a favourable decision can be received soon.
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