by Rae Halliday
The National Health Service was founded in 1948 on the principles of providing a ‘universal service for all based on clinical need, not ability to pay’. Today, the first guiding principle for the NHS remains that ‘the NHS provides a comprehensive service, available to all’. Despite this, every year people in clinical need are turned away at the point of care, due to restrictions imposed not by the NHS or medical professionals, but by the Home Office.
Migrant health is a complex and volatile issue, with policy regularly changing in response to public opinion and parliamentary agenda. This often leaves those without legal expertise or access to specialised migrant health services in the dark about which NHS services they are entitled to. These entitlements can be considered in three broad categories: those with indefinite leave to remain or British citizenship, those with limited leave to remain, and those without immigration documentation. Currently, charging policy is applied to the latter two parts of the population and all charges must be paid in full before treatment is offered, except for where treatment is considered ‘urgent’ and ‘immediately necessary’. This works directly against the ethical framework underpinning the NHS. Being aware of the entitlements of each potential patient group is fundamental to understanding the role of healthcare professionals as advocates and activists navigating this system.
For those who do not have immigration documentation, including individuals who have been refused asylum, health care access is restricted to primary care services, A&E, family planning (excluding abortion services), palliative care and diagnosis and treatment for a limited number of communicable diseases. Beyond this, all secondary care services, including treatment for chronic conditions such as renal dialysis, cancer treatment and treatment following admittance to A&E, are all chargeable at 150% the standard service cost to the NHS.
These costs can have devastating consequences for those in need of specialised care. Patients Not Passports is a campaign developed by Docs Not Cops, MedAct and Migrants Organise and works to challenge health care charging in the UK. This year, they launched a campaign in support of Simba Mujakachi, who in June 2019 suffered a stroke which caused life-changing health consequences. Two weeks after his stroke, whilst in a rehabilitation unit, Simba was presented with a bill of £93,000. As someone who has been refused asylum in the UK, Simba is unable to work or access Universal Credit, leaving him unable to settle this debt. This is not an isolated incident, every year an unknown number of people are presented with unaffordable health care costs, are refused treatment, or do not seek health care at all due to the mounting number of financial and legal barriers involved in engaging with the NHS.
Difficulties accessing health care aren’t limited to those without immigration documentation. In addition to standard Home Office fees, applicants for visas to stay in the UK for 6 months or more are required to pay an annual immigration health surcharge of £624 to access NHS services. As most of these visa holders can access employment, this surcharge is often paid alongside income tax and national insurance, creating parallel contributions towards the NHS and an unnecessary financial burden for applicants. Whilst this presents a significant financial barrier for many, non-payment of the surcharge and subsequent chargeable NHS treatments may cause problems obtaining future visas. According to current regulations, the personal information of individuals with outstanding NHS debts of over £500 for 2 months must be reported to the Home Office, who have stated NHS debt will be considered when considering future applications for leave to remain.
Even for those with no legal restrictions to healthcare, such as refugees and asylum applicants, social and cultural barriers to health care access may still exist. A 2019 study found that barriers involved language, inadequate interpretation services and perceptions of discrimination relating to race, religion, and immigration status . Furthermore, many have faced denied primary care registrations due to requests for proof of address, identification, or proof of immigrations status, none of which are legally required to access primary care in the UK. Gatekeeping essential services through identification checks may put an individual’s health at risk, whilst reinforcing poor experiences that may be preventing excluded communities from seeking needed services in the future.
A common issue reported across migrant groups is fear of information sharing with the Home Office. NHS data sharing has created a culture of fear and distrust, with those who have an insecure immigration status feeling unable to engage with health services for fear of immigration enforcement arriving at their door. Furthermore, clinicians are reporting pressure from Health Boards to flag and report any patients suspected of not being entitled to free treatment. This works directly against healthcare professional’s duty of care for their patients and legal responsibility to safeguard patient confidentiality, placing clinicians in ethical dilemmas and creating dangerous additional administrative burdens.
Despite the multiple barriers to healthcare, political rhetoric around charging is yet to match the evidence base. Studies consistently show that charging for healthcare is costing the NHS more in administration and debt collection fees than is ever recovered. In addition, claims of the cost to the NHS of ‘health tourism’ have been shown to be wildly inflated, and that the reason for migration is rarely in search of health care. Finally, gatekeeping of primary care and inaccessible services have been shown to prevent people seeking support until medical needs are urgent. This forces individuals to present in A&E, putting increased strain on emergency services and creating unnecessary health risks for patients.
Migrant Health and Covid-19
The Covid-19 pandemic has highlighted the dangers of a health care service that excludes parts of the population. Earlier in the year Doctors of the World UK released a briefing on access to healthcare services for excluded groups, including migrants, during the pandemic. This highlighted how access to services, in addition to Covid-19 guidance and key public health messages, was a particular challenge for migrants, primarily due to digital exclusion and language barriers .
In April, over 60 cross-party MPs wrote to the Health Secretary, Matt Hancock, calling for the immediate suspension of charging for migrants and all associated data-sharing and immigration checks, following reports of the tragic deaths of people without immigration documentation who did not seek medical care when experiencing Covid-19 symptoms, due to fears of charging and legal consequences. These deaths are a devastating reminder of the unjustifiable consequences healthcare charging has on migrant communities.
How can I get involved?
Whilst healthcare professionals should never be required to act as immigration enforcement, it is crucial we educate ourselves, colleagues and our communities in order to support all those who require NHS services.
As healthcare students, professionals or as members of our wider health communities, we can:
- Educate ourselves and our community, the Patients Not Passports campaign has created useful advocacy guides for healthcare professionals and community members for this
- Challenge others when we see patients being asked for proof of immigration status, this may be putting the patient’s health at risk
- Contact your local MP, charging policy can be changed, but it starts with individual and community action
Finally, to keep up to date on current campaigns you can follow the Hands Up for Our Health campaign. The campaign is a national coalition of public health organisations, including Students for Global Health, working to challenge barriers to healthcare access in the UK. The coalition aims to achieve: suspension of NHS charging during the Covid-19 pandemic, investigation of the impact of NHS charging on the communities affected, and to influence the UK government to build back NHS services in a more equitable and accessible way following Covid-19.
1. Kang C, Tomkow L, Farrington R. Access to primary health care for asylum seekers and refugees: a qualitative study of service user experiences in the UK. British Journal of General Practice. 2019;69(685):e537.
2. Doctors of the World UK. An Unsafe Distance: The Impact of the COVID-19 Pandemic on Excluded People in England. London; 2020.