Hostile health care: why charging migrants will harm the most vulnerable

INTRODUCTION

In 2013, the number of international migrants worldwide reached 232 million.¹ With ever-increasing human mobility, migration is a leading policy issue of the 21st century.² In the UK, migrants’ access to NHS health care is to be further restricted by the proposed health reforms as part of the Immigration Act. The Home Secretary, Theresa May described it as seeking to create a ‘hostile environment for illegal immigrants’.³

The Immigration Act provides the foundation for a substantial and concerning change in policy on migrants’ access to health care: a policy devised, consulted on, and intended to be delivered by both the Home Office and Department of Health (DoH).⁴ The proposals include a health surcharge to be paid by migrants from non-European Economic Areas (EEAs), eligibility testing to be implemented in primary care, charging for accident and emergency (A&E), extra prescription fees, and higher rates for using opticians, dentists, and other community services. These proposals will harm the most vulnerable groups including pregnant women, threaten public health, and will ultimately lead to widening health inequality in the UK. The Royal College of General Practitioners (RCGP) states that:

‘General practice should remain the main access to health care within the NHS ... GPs have a duty of care to all people seeking health care ... [and] should not be expected to police access to health care or turn people away when they are at their most vulnerable.’ ⁵

As a volunteer for Doctors of the World (DOTW) I see many vulnerable migrants who are regularly turned away by general practices. DOTW UK is part of the Médecins du Monde network, an international humanitarian medical organisation with projects world wide. In the UK, we run a volunteer-led clinic and advocacy project in east London helping people access health care. We see all vulnerable groups, but a large proportion of these are ‘irregular’ migrants, often referred to as ‘illegal immigrants’ by politicians. Many are from non-EEA countries; failed asylum seekers, visa over-stayers, victims of human trafficking, and domestic servitude. Over the past year, two-thirds of our patients in the clinic reported difficulty accessing health care and one in five feared arrest by seeking medical help.⁶

Reproduced with permission from octors of the World. D

UK MIGRATION

Immigration increased throughout the 2000s, with a peak in net migration in 2004–2005 due to the expansion of the European Union (EU). Since then, annual net migration has fluctuated between around 150 000 and 250 000. Although net migration of EU citizens is still on the rise, net migration of non-EU citizens has declined over the past few years. In the year ending September 2013, 244 000 non-EU migrants came to the UK, a statistically significant decrease compared to the estimate of 269 000 in the year ending September 2012.⁷ Estimating the number of irregular migrants is more complicated. Research by London School of Economics suggests the numbers oscillate between 417 000 and 863 000, including a population of UK-born children ranging between 44 000 and 144 000. They estimated that 67 per cent to 73 per cent of all irregular migrants live in London.⁸

From a public health policy perspective, there is an important dichotomy between documented and irregular migrants. Migrants who travel with the correct documentation through legal channels, such as high-skilled labourers, are likely to encounter fewer health risks and have better access to services than irregular migrants.⁹

IMMIGRATION ACT

The Immigration Act will introduce a health levy for migrants with time-limited immigration status, such as certain categories of workers and students, who apply for leave to enter or remain in the UK. The government hopes to recoup £500 million with its proposed levy, yet as the RCGP warn; it is unlikely this will even cover the administrative costs.¹⁰

The Act will also extend the group of migrants who may be charged for access to NHS treatment to cover all those subject to immigration control who do not have indefinite leave to enter or remain, that is, permanent residence. In order to incentivise the NHS, non-EU migrants will be charged 150% of the NHS tariff. The government intends that certain groups such as asylum-seekers, refugees, children in local authority care, and recognised survivors of trafficking will continue to be exempt from charges.¹¹ However, we see many victims of trafficking in clinic who have not or do not want to be referred to the National Referral Mechanism. It is estimated that over two-thirds of victims of trafficking are not recognised by the state.¹²

POTENTIAL CONSEQUENCES

The Immigration Minister, Mr Mark Harper MP, said:

‘ … we will not do anything that will worsen public health. Of course it is important for those who are in the United Kingdom, even if they are not here legally, to have access to public health treatment, because it has an impact not just on them, but on the rest of the community.’

The government believes that by keeping GP consultations and treatment for certain infectious disease ‘free to all’, public health will be protected. Yet free care will not protect public health if people cannot access it in the first place.

Even in the current system, vulnerable migrants face administrative barriers that prevent them from registering with GPs. For example, we recently 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. Despite clear guidance from the DoH and RCGP, there is considerable misunderstanding at a local level regarding who is eligible to register with a GP. We are frequently faced with front-line staff that misunderstand the regulations and deny care to those who are eligible. This has been fuelled by the media attention that the Immigration Act has gained.

To track eligibility the DoH proposes to introduce a more rigorous registration system with GPs that will further exacerbate the situation. GP practices will be expected to assess chargeability and link this information to a patient’s NHS number and record.¹¹ Vulnerable migrants are even less likely to be able or willing to access free primary care. Contagious and chronic disease will go undetected and untreated, and migrant children will not receive immunisations, essential for not only their health but to maintain herd immunity.

The DoH proposes that eligibility data collected in primary care should be shared across government departments including the Home Office and HM Revenue & Customs.¹¹ Effectively GPs will be expected to act as immigration police, jeopardising the doctor–patient relationship and duty of care. Linking health care directly to the Home Office will act as a serious deterrent for many of our patients.

A further threat to public health is the proposed charges for A&E. The DoH states this will alleviate over-stretched emergency departments of unnecessary attendances.¹¹ Yet the additional bureaucracy of determining who is chargeable (and for how much), is likely to be more of a burden to busy staff, could compromise clinical care and is ethically questionable. Charging will deter those who cannot afford to pay, resulting in later presentations to A&E, higher morbidity and mortality, and ultimately more costly treatment.

CONCERN FOR PREGNANT WOMEN

Despite overwhelming support in the public consultation to protect pregnant women from additional charging, the DoH will not be introducing exemptions for maternity services due to concern about health tourism ‘increasing significantly’. The government’s limited research concludes that estimates of so-called ‘health tourism’ remain ‘speculative’.¹¹ Seven years of DOTW data shows that our patients have been living in the UK for more than 3 years before trying to access care. Just 1.6% of people using our service had left their country of origin for health reasons.⁶ In 2013 we saw 97 pregnant women in clinic. Of these, 72% were not accessing antenatal care. These women are not health tourists. They are vulnerable, 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 (http://www.hqip.org.uk/cmace-reports/). These are some of the neediest women in society, yet they are not receiving necessary and urgent care due to restrictive government policy.

CONCLUSION

Sensible immigration policies are still required; those who can pay for health care should. As a society we have the means to protect the most vulnerable groups. Further restricting or deterring access to health care is inhumane and unethical. To protect public health and reduce health inequalities, access to primary care should be made easier. GPs should not be asked to act as immigration police, sharing information with the Home Office and jeopardising their duty of care. Maternity care should be exempt from charging, as should all vulnerable migrants (Box 1). If the DoH proposals go ahead, we will see a surge in demand for our service: a humanitarian medical organisation responding to a healthcare crisis within the UK.

Box 1. What can you do?

• Check your own practice’s registration procedures and do not unintentionally exclude the most vulnerable.

• Volunteer for DOTW: http://doctorsoftheworld.org.uk/pages/get-involved.

Provenance

Freely submitted; not externally peer reviewed.