This week, I asked Hannah, our previous Research Deputy, to write for the blog about Migrant Health in the UK. Here, she discusses some of the issues faced by those who cannot access the NHS freely. We believe that health should be a human right and we argue that, as primary care physicians, we should remain free at the point of access and not be mistaken as border control officers.

Migrant Access to NHS Healthcare

In 2013, the International Organization for Migration estimated there were 232 million international migrants worldwide, with nearly 50% living in more developed countries.  This is predicted to rise to 405 million by 2050.  Rather than accommodating migrants, the UK is developing ever more restrictive policies and regulations.  The NHS relies heavily on migrant workers from cleaners to consultants, yet the government are introducing more checks and charges.  This is in an attempt to ‘recoup’ money, and many argue scapegoat migrants for a failing healthcare system.

As home secretary, Theresa May sought to create a more ‘hostile environment for illegal immigrants’, and restricting access to NHS care was part of this agenda. Now as Prime Minister she is making more changes and even certain primary care services are being charged for.  Charitable organisations such as Doctors of the World have evidence that this is jeopardising the health and wellbeing of the most vulnerable people in our society and increasing inequality in the UK.  

In this blog post I will guide you briefly through key policy changes, the groups affected and signpost you to important campaigns.  

What are the key changes that have been made?

• Immigration Act

Passed in 2014 the Immigration Act introduced a health surcharge (£200 per annum for  all non-EEA migrants intending to stay for longer than 6 months).  All those subject to immigration control who do not have indefinite leave to enter or remain (that is, permanent residence) could be charged for secondary care. All those charged have to pay 150% of the NHS tariff.

Certain groups are exempt from these charges: asylum-seekers, refugees, children in local authority care, and recognised survivors of trafficking (this list is not exhaustive, see here for further details)

However, in the Doctors of the World clinic where I volunteer, we see many survivors of trafficking who have not or do not want to be referred to the National Referral Mechanism. It is estimated that over two-thirds of survivors of trafficking are not recognised by the state.  

2) Overseas visitor and migrant NHS cost recovery programme

Since 2015 the government have been consulting on extending charges further (see Making a Fair Contribution).  Worryingly:

• In April 2017 the law changed, with the introduction of passport checks for all patients accessing NHS services and up-front charging for migrants who do not qualify for free care. These changes were piloted in over 20 hospitals and are due to come into full effect from the 23rd October 2017.
• Further charges will be introduced for primary care services and non-NHS providers of NHS-funded care. This includes prescription charges, dental care and ophthalmic services.  Patients using community services such as mental health services, including those provided by charities, will have their paperwork checked and may be charged.

What are the implications of these changes?

These changes are seriously concerning for multiple reasons, and do not just affect migrants but our society as a whole.  They:

• Will cause individuals to delay seeking treatment early in an illness, leading to late presentation, more serious illness and costly care
• Unfairly penalise migrants (migrants contribute £630,000,000 to the UK economy)
• Risk public health with untreated infectious disease, poorly managed non-communicable disease and lower uptake of immunisations

• Turn the NHS into a border control agency
• May cost more than they save

These additional administrative systems have not been evaluated.  The government report states  “data was unavailable to allow a comprehensive cost benefit analysis for the implementation of the Cost Recovery Programme” – in other words it may cost more than it recoups!

Many healthcare workers feel that the government is using the NHS as a further border control agency, jeopardising relationships with patients and patient care.  Have a look at the campaign #PatientsNotPassports and #StopSharing.  There is also the real fear of increased discrimination and racial profiling.

GP care is free to all (at the moment)

Currently anyone (including undocumented migrants) can register with a GP and see a GP or nurse for free.  However, many vulnerable migrants struggle to register as nearly all GPs ask for photo ID and proof of address.  Barriers are already in place.  With increasing links to the Home Office (#StopSharing), and hospital and certain community services needing to check passports before treatment is given, these groups will be increasingly deterred.  

Vulnerable groups

Vulnerable groups such as pregnant women ARE NOT exempt from charging. In 2013 in the Doctors of the World clinic we saw 97 pregnant women. Of these, 72% were not accessing antenatal care. Many live in abject poverty, are socially excluded and are being presented with unmanageable hospital bills.

We saw a 32-year-old Nigerian woman who was not accessing care because she was scared of the cost. She came to see us at 23 weeks pregnant feeling lethargic and unwell. We sent her to A&E where she was admitted with an infection. At discharge she was reassured that all was well with her baby. Two weeks later she went into premature labour, was admitted to hospital and the baby died. This may have been preventable if she had attended routine antenatal appointments. The majority of the women we see in clinic have multiple risk factors for increased pregnancy-related morbidity and mortality, as recognised in the Centre for Maternal and Child Enquiries reports.

Undocumented migrants, such as failed asylum seekers or those smuggled into the UK will be fearful of accessing care.  

For example, in the Doctors of the World clinic we saw an Afghani couple who were in their late 60s, failed asylum seekers, destitute, and homeless. The wife was clearly struggling to care for her husband, who had multiple chronic health problems including a history of neurosurgery for a tumour. She carried his medications around in a dirty supermarket carrier bag. Before coming to the DOTW clinic they had been turned away by several GP surgeries that had refused to register them due to lack of documentation. We are frequently faced with front-line staff who misunderstand the regulations and deny care to those who are eligible.

The UK is a wealthy society and boasts one of the best healthcare systems in the world.  However with politicians driving an agenda to restrict care to migrants we will see increasing health inequalities and an erosion of trust in healthcare professionals.  As GPs we have a central role in addressing both causes and consequences of health inequalities in the UK – we need to fight to stop patients being deterred from accessing care #PatientsNotPassports

Glossary of terms

Asylum seeker: An asylum seeker is someone who has lodged an application for protection on the basis of the Refugee Convention or Article 3 of the ECHR.

llegal Entrant: This term is applied to people who enter the country by clandestine means (such as hiding in a lorry), by deception (which can include lying about identity or using false documents) or are in the country in breach of a deportation order.

Refugee: A refugee is a person who ‘owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country…’ (Definition quoted from the 1951 Refugee Convention)

If you are interested in reading more I would recommend:

“Migration, Illness & Health Care” by Jenny Altshculer