At NAT (National AIDS Trust) we are deeply concerned by these new regulations. Refused asylum seekers and undocumented migrants often have acute healthcare needs, and putting up a barrier to accessing healthcare services for these vulnerable groups will cost the NHS more in the long-term, putting both individual and public health at risk. Undocumented migrants are often destitute, with little to no ability to pay for their healthcare. While there has been much attention on this issue publicly, the actual amount that the NHS spends on care for chargeable migrants currently equates to less than 0.5% of the entire NHS budget.
The Five Year Forward View contains an important message about prevention
National Voices members know that our health service cannot be sustained unless the NHS focuses more on intervening early and preventing serious acute health needs. NAT believes these charges have the opposite effect, by keeping vulnerable patients away from services until things become urgent.
At NAT, our focus is HIV and public health. HIV treatment and care became exempt from charging in 2012 after a concerted effort on behalf of the HIV sector to make the case for HIV as a public health priority. Unfortunately, this approach is not being extended to other vital public health and mental health services. Under the new regulations, mental health services, drug support services and community services will be denied to undocumented migrants who cannot pay. Charging migrants for drug and alcohol services will push heavily stigmatised communities further into the fringes of society, prevent people from accessing safer injecting methods and increase the onward transmission of blood-borne viruses. Even if HIV prevention and treatment are currently both free, if undocumented migrants cannot access other vitally important elements of healthcare then the positive impact from HIV services not being chargeable may be compromised.
It is easy to see how this issue runs deeper than just HIV and infectious disease. Community services should be the bedrock of our health service, forging links between patients, communities, and the health professionals that support them, with the potential to give people more of a voice in the care they receive. The door is now being closed on these effective forms of care for vulnerable communities. NHS funded community services will be obliged to check immigration status and may have to charge people directly, breaking down trust and introducing checks that are bureaucratic and unlikely to be cost effective. Charging migrants for mental health services will continue to marginalise a group of people already disproportionately affected by mental illness. Many of the women excluded from free NHS care have limited access to contraception; this includes sex workers and trafficking victims. Access to abortion for women who have been raped, work in the sex industry or are unable to access contraception is essential, and restricting access to this service will increase illegal and unsafe abortions.
The regulations will only exacerbate existing health inequalities in society
Upfront charging may even deter vulnerable people from accessing healthcare altogether, worrying they must pay for care even where exemptions are in place. Exemptions from charging are in place for certain groups such as asylum seekers who are yet to hear the result of their asylum claim - but the system of reclaiming costs is confusing and complex for NHS staff to understand and implement, leading to examples of patients being wrongly denied treatment. In a system where some people are exempt from charging and others not, and certain treatments are exempt from charging but others are not, how do we expect patients (or NHS administrators) to understand what they can and cannot access?
Currently treatment cannot be denied in cases where clinicians deem the treatment ‘immediately necessary’ or ‘urgent’ – situations where an acute need is becoming life-threatening – but chargeable patients will still be billed afterwards, whether or not they have the ability to pay. It is therefore counterproductive to charge migrants for many aspects of healthcare. It seems likely that where chargeable patients choose to not access treatment for fear of being charged, they will then present later on with more acute health issues where the need for treatment will be ‘immediately necessary’ or ‘urgent’, all at a greater cost to the NHS.
The Department of Health wishes to extend charging into primary care
If this goes ahead, the impact on health-seeking behaviour of marginalised groups will be dramatic. The charity Doctors of the World run a volunteer-led clinic with GPs and nurses that help people from vulnerable communities’ access healthcare. They showed in a study into diabetes that providing undocumented migrants with entitlement to primary healthcare would lead to earlier diagnosis and prevent diabetes-related complications, saving the NHS at least £1.2 million and 832 years of healthy living (quality-adjusted life years) in relation to type II diabetes alone. Primary care is often the first point of entry for most people into the NHS, where conditions can be diagnosed early, leading to better outcomes for both individual and public health.
The concept of person-centred care, which has been so championed by us all as members of National Voices is being fundamentally threatened for a certain subgroup of society. How can a person be at the centre of their care when they are denied care altogether? This is why National Voices members should be concerned by our healthcare becoming one of the most restrictive systems in Europe for undocumented migrants.
For more information on this topic please contact Christopher Hicks at NAT (Christopher.firstname.lastname@example.org), or for specific advice and support on migrant healthcare please contact Lucy Jones at Doctors of the World (LJones@doctorsoftheworld.org.uk)