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Changes to Accessing Healthcare – Impact on Refugees & Asylum-Seekers

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“One of the consequences of universality of the British National Health Service is the free treatment of foreign visitors. This has given rise to a great deal of criticism, most of it ill-informed and some of it deliberately mischievous. Why should people come to Britain and enjoy the benefits of the free Health Service when they do not subscribe to the national revenues? So the argument goes. … there are a number of more potent reasons why it would be unwise as well as mean to withhold the free service from the visitor to Britain. How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? For if the sheep are to be separated from the goats both must be classified…” 

Aneurin Bevan, founder of the National Health Service, In place of fear, 1952

When the NHS was created in 1948 by the then Minister of Health, Aneurin Bevin, it was based on the ideal that good healthcare should be available to all, regardless of wealth. Indeed, the three core principles on which it was based included the need to ensure comprehensive treatment, guarantee universal access based on need not the ability to pay, and be free at the point of delivery. While the NHS remains a model of healthcare that many nations around the globe would aspire to, there has been a steady drift away from these core principles over time.

Most recently, the Government has proposed to amend a set of rules, known as the ‘NHS Charging Regulations’, which govern how people access healthcare and when they have to pay for it. We are deeply concerned that these changes will deter even more people from accessing treatment, remove essential services from hard to reach communities and result in increased health inequalities among the general population. Moreover, rather than saving the NHS money, these changes are likely to lead to greater costs in the form of increased patient waiting times, and by creating an additional administrative burden.

We’re campaigning to ensure that these substantial changes to accessing healthcare are properly scrutinised by Parliament and we need your help to raise awareness of their impact in your community and with your MP. Read more on the impact of the changes below and scroll down to the ‘take action’ section to learn more about what you can do.

The Current Charging Regime in NHS England

Currently, some people in England are not entitled to free NHS hospital care, such as people who are here for short-term visits and undocumented migrants. Refugees and people seeking asylum are exempt from paying for treatment. However, refused asylum seekers have different entitlements and only those in receipt of some form of statutory support (Home Office Section 4/ Section 95 support or Local Authority support) are entitled to free care. However, in England, refused asylum seekers who are not in receipt of support are currently chargeable for secondary (hospital) care. There are already processes in place for hospitals to identify and bill patients for their care.

Some NHS Services also remain free to everyone, such as family planning services, compulsory mental health care, treatment for a range of communicable diseases that might pose a public health risk, and treatment provided in a sexually transmitted diseases clinic, among others. Access to GP services and A&E services is currently free to all, although the Department of Health have indicated this may be subject to review at a later date.

Proposed Changes to Accessing Healthcare

As part of the new regulations, the Government is making two significant changes to the above.

Firstly, effective from August 2017, healthcare charges will be introduced for services provided by all community health organisations in England, except GP surgeries. Any organisation receiving NHS funding will be legally required to check every patient before they receive a service to see whether they should pay for their care and, in some circumstances, patients will be charged for accessing these services.  A wide range of health services may be affected, including, as we read the regulations, public health services commissioned through Local Authorities such as public mental health and drug and alcohol services.

Secondly, from October 2017, the regulations will introduce a legal requirement for all hospital departments and all community health services to check every patient’s paperwork – including passports and proof of address – and charge up front for healthcare, refusing non-urgent care where a patient cannot pay. This means that every patient, British citizen or person under immigration control, will be asked about their residency status and will need to prove they are entitled to free NHS care. If a patient cannot prove that they are entitled to free care, they will receive an estimated bill for their treatment and will have to pay it in full before they receive any treatment other than that which is ‘urgent’ or ‘immediately necessary’, as defined by doctors on a case-by-case basis.

Impact on Refugees & People Seeking Asylum

We fear that the impact of these changes will be to further deter vulnerable people from accessing treatment, even those who are eligible, like refugees and people seeking asylum, by adding additional barriers in the form of documentation and up-front charging. Even under the current system, it is difficult for health services to accurately identify who is chargeable under the regulations and who is exempt, particularly when the immigration status of individuals regularly changes over time. Those who are most adversely affected are often the most vulnerable, who have little understanding of their rights or ability to advocate for themselves and navigate the NHS, particularly without a translator. There is a risk that healthcare, including lifesaving care, may be withheld from refugees and asylum seekers who are entitled to free care because they do not have easy access to paperwork and passports to prove entitlement.

In addition, these changes threaten to remove crucial services from hard-to-reach sectors of society, such as refused asylum-seekers who will now be chargeable for a range of community health services in England. The introduction of these charges to services which are often specifically commissioned to reach marginalised communities and individuals unlikely to seek out NHS care undermines the vital role they play in protecting public health and safeguarding vulnerable people.

People who have been through the asylum system often have particular physical and mental health needs, given their experiences in their countries of origin and their journey to the UK, in addition to the poverty, homelessness and social isolation that many will experience in the UK. For refused asylum-seekers with no permission to work in the UK, they are unlikely to have any means of paying for health services, and will be deterred from accessing even those services that are free for public health reasons due to fear of being charged at a later date, or being identified by the Home Office. It is notable that the Welsh and Scottish governments, and Northern Irish Assembly have seen fit to exempt this group from charging.

Impact on Public Health & the NHS

Taken together, the extension of charging into community care services, coupled with the likelihood that public health services commissioned through Local Authorities – such as drug and alcohol services – will also be affected by the regulations, mean that access to immunisation programmes, early diagnosis of communicable diseases, and other preventative care programmes which protect us all will be undermined.

In addition, it is unlikely that these changes will save the NHS money – in fact, it is likely that it will actually cost the NHS more money to administer than any potential savings. The anticipated financial saving for the NHS is small (£200,000 a year), based on little evidence and likely to be overestimated. In addition, the confusion around eligibility will result in late diagnosis and treatment amongst groups most at risk, with significant long-term costs to the NHS, particularly when considering that emergency interventions undertaken after an individual’s health has deteriorated require urgent or immediately necessary treatment. These new systems to check patient eligibility will likely have more far-reaching consequences as ID checks will be carried out on all patients in advance of appointments, and medical professionals are tasked with judging whether treatment is urgent or immediately necessary. This is very likely to increase patient waiting times, putting the NHS under even greater strain.

Finally, as the above quote from the NHS founder suggested, the only way to check eligibility for free NHS services which does not contravene equality law is to check everyone. Reviewing every patients’ immigration status will be time consuming, costly to administer and frustrating for both patients and NHS staff. It is difficult to see how repeat eligibility checks can be avoided as service providers will have to ensure that a patient’s residency status in the UK has not changed over time.

Our Recommendations

Together with Doctors of the World, the National Aids Trust and many others, we are calling on the government to withdraw these regulations and carry out and make public the results of a comprehensive  impact assessment. On completion of the above, we’re asking that any further regulations to extend charging or introduce upfront charging should include certain exemptions. For a full list of recommendations please download Asylum Matters – Healthcare Regulations Briefing 2017 

What You Can Do

  • For the latest information on urgent actions, please see here
  • Raise awareness on social media about the changes using #PatientsNotPassports and download our Health Charging Regulations – Social Media Guide for examples of tweets and messaging, and find some visuals to share here:  Images for health regs campaign. 
  • Raise awareness on social media about the changes using #PatientsNotPassports. Our social media guide will shortly be available here but do start tweeting and help us build momentum behind the campaign.
  • Raise the issue with your local Health and Wellbeing Board and Clinical Commissioning Group, asking the Chair to write to the Secretary of State for Health outlining their concerns.
  • Let us know if you or someone you know is a healthcare professional or part of a charity or social enterprise that is likely to be impacted by these changes. You could write to your employer, union or royal college, raising concerns around the impact of the regulations on patients, or the unworkable bureaucratic burden on your organisation that would prevent you from providing essential services. We’re also looking for spokespeople on the issue so do get in touch if you’d be willing to raise the issue publicly, by contacting Estelle on [email protected].

For any other ideas or questions, we’d be happy to hear from you so please do email Estelle at Asylum Matters on [email protected].

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