DotW and the clinic
Thanks for the invite so speak this evening and join in the discussion on this important topic.
DotW is a medical humanitarian organisation, providing healthcare through over 300
projects in 70 different countries to people who are otherwise unable to access care.
I coordinate our clinic in east London where we see over 1,500 people a year. Nearly all of
them are struggling to access mainstream health services, so as well as providing a medical
service, a key component of our work is advocating on their behalf to ensure that they can
access appropriate mainstream care.
Who we help in the clinic
The majority of the people we see at our clinic are vulnerable migrants. Whether these are
people who have overstayed their visas, are failed asylum seekers, irregular entrants,
victims of human trafficking or people working in domestic servitude, the thing they have in
common is that they are unable to access the most basic healthcare.
The current situation: legislation vs reality
At the moment, primary care (that is, registration with a family doctor) is accessible to all –
GPs have the discretion to register whoever they like. However the reality that we are
seeing week in, week out at our clinic, is that many GP surgeries (in London at least) are
already demanding to see proof that patients’ have a ‘regular’ immigration status before
allowing them to register.
There are other barriers to care too - the documents required before registering with a GP
create a bureaucratic hurdle that many find difficult and sometimes impossible to
overcome. Frontline staff often misunderstand the rules and deny access to healthcare for
those fully entitled. Then there often language barriers, and at times cultural barriers.
People also fear accessing health services – 20% of patients surveyed at DotW feared arrest
if they accessed health care.
At secondary care, there are restrictions that apply – whilst asylum seekers (and failed
asylum seekers receiving Section 4), refugees and others with specific visas are eligible to
free NHS care, undocumented migrants are not. Care in A+E is free, as is treatment for
infectious diseases such as TB or HIV. ‘Immediate’ or ‘urgently necessary’ treatment must
always be given even if later chargeable. This particularly affects pregnant women. We see
many who, having attending their first scan, are put off receiving further care because they
have been presented with a bill, or warned that they will be reported to the UK Border
Agency if they cannot pay.
Public consultation; immigration bill
It is in this context that DotW views with concern the proposals that the government
outlined in their consultation over the summer regarding the charging of migrants for access
to healthcare. These changes to the healthcare system will be pushed through as part of an
immigration bill.
The DoH has yet to publish its response to the public consultation. The first and second
readings of the bill took place in October, and it is expected to pass through the Lords in
December.
The proposed changes: do they make sense and what will their impact be?
The bill proposes imposing an up front £200 levy on migrants to use the NHS. The details of
this are not yet clear – how will this be implemented and who will implement it? How are
healthcare providers expected to determine eligibility without being discriminatory? What
will happen to those who simply cannot afford to pay?
Before considering the possible implications of these changes let’s take a step back and
consider first why are they being implemented.
Quite simply, it’s politics. The NHS is political; immigration is political. Put these two
together and you have combination guaranteed to get you headlines. The NHS routinely
comes under attack – we’re constantly being reminded that it is failing; falling apart. One of
the mains reasons for this is apparently “health tourism”. It is a popular argument that
quickly builds up steam, and comfortingly means that we can allocate the blame for our
problems at someone else’s door.
Unfortunately it is an argument devoid of facts. Estimates of the costs of overseas visitors
range from £12m to £70m – to put that into context that is between 0.01% and 0.06% of the
NHS budget.
The proposed solution to this simply doesn’t add up. The government hopes to recoup
£500m with its proposed levy, yet as the RCGP and the BMA warn, it is unlikely that this will
even cover the cost of implementing the bureaucracy this new system will require.
Furthermore, we already see daily that there are already plenty of barriers that prevent
migrants from accessing healthcare. Creating further barriers will put people off accessing
healthcare, whether or not they are entitled to it.
I’m going to tell you about two patients we have seen at the clinic recently. Kumar is a
refused asylum seeker from Sri Lanka with acute mental health needs. Having witnessed the
murder of his brother, he is severely depressed and he hears voices. With the medication he
was prescribed by his GP he was able to cope. However, he was deregistered following a
bureaucratic error at the surgery, and had been off his meds for 4 weeks by the time he
came to us. We were extremely concerned by his situation and by the mental health needs
he was presenting with - we arranged for an emergency appointment for him within 24
hours where a concerned GP prescribed him with an emergency supply of medication.
Despite that, the surgery continues to refuse to register him, for no discernable, logical
reason.
Then there was an Afghan couple, in their late 60s, refused asylum seekers, destitute and
homeless, relying on the support of religious organisations to give them shelter at night. The
wife was clearly struggling to care for the husband, who had previously had brain surgery to
remove a tumour, and carried his medication around with him in a dirty supermarket carrier
bag. Before coming to our clinic they had been turned away by several GP surgeries that had
refused to provide them with any basic care.
We should be ashamed that this happens in the UK.
Let us be clear – anti-immigrant rhetoric has a direct impact on the health of people who are
often already in vulnerable situations. When Theresa May and Jeremy Hunt, or certain
sections of the media, stoke public fear around migrants and their use of the NHS – the
result is patients being denied access to basic healthcare. This can only end up with sick
people getting more sick.
So clearly, from a humanitarian perspective, denying someone access to healthcare
because of where they are from or who they are is just plain wrong.
From a Public Health perspective – by preventing or dissuading people from accessing care
we risk infectious diseased going undetected and untreated.
We hear from medical professionals that being told who they can and cannot treat creates
clear ethical challenges concerning their duty of care to the patient.
Also, the economic argument does not add up. Vulnerable migrants are already having
difficulty accessing primary care – by imposing further barriers (be it at primary or
secondary care) we run the risk that fewer people will access care appropriately, that people
will wait until they are seriously ill before accessing care – at a greater cost to them and to
society at large who will end up paying more.
The cost of late care for medical conditions and complications largely outweighs any short
term savings. For instance a chest infection that could be treated with a simple course of
antibiotics for under £10 could end up with someone being admitted to A+E at a far greater
cost.
Let’s face it, if you are unfortunate enough to have to visit a hospital, you are far more likely
to be treated by a migrant than see a migrant as a fellow patient. Over 30% of NHS staff are
estimated to come from abroad.
Our European cousins
In Spain a similar policy was implemented by royal decree over a year ago there. Despite
widespread protests from doctors, 870,000 migrants were declared ineligible for healthcare
overnight. Our colleagues at Doctors of the World in Spain are adamant that restricting
access to healthcare has not only been unjust and irresponsible, but ineffective and
dangerous. They tell us that the standard of healthcare has deteriorated; that there is a lack
of coordination between primary and secondary care; and that the impact has been felt
particularly by women and children. Doctors are faced with the dilemma of breaking the law
or not treating patients they know need treatment. Is this a road we want to go down?
In Sweden, a country often cited as a leader in equality within Europe, they are moving in
the opposite direction, opening up their health system to make it more - not less - accessible
to migrants. This is because they recognise the long-term impact of assuring universal
healthcare benefits society as a whole.
At Doctors of the World we are anticipating that these health reforms will lead to an
increase in demand for our service – the prospect of a humanitarian medical organisation
needing to respond to health reforms is a real one. One of the founding principles of the
NHS was its universal access. Back then in 1948 it was clear, just as it should be now, that
healthcare is not a luxury; it’s a human right.