Medact believes that healthcare should be freely accessible for all who need it on ethical, humanitarian, public health and economic grounds.
However, the government’s current policy trajectory is set to further hinder migrant access to healthcare services a move that is likely to cost considerably more than is being made apparent.
We see these proposals as being:
- Fundamentally unethical and in contravention of Human Rights Legislation;
- Unsafe and harmful to the wider public;
- Costly, un-economic and wasteful;
- Helping to create the infrastructure for widespread charging across the NHS.
For this reason, Medact is working to raise the profile of these changes and provide an evidence-base for negative health implications of the proposed changes.
These proposals raise significant concerns in the following areas:
Lack of information and evidence; no economic case
The government’s proposals fundamentally lack a financial, economic or public health rationale. What evidence-base is provided, has worrying flaws that lead us to question its validity. The Qualitative research component, totalling over 500 pages, contains significant reporting and selection biases. Of its “circa 150” respondents, only 59 were healthcare professionals, whilst Overseas Visitors Officers (OVO) provided both the expert briefings and acted as a conduit for the selection of other respondents.
In general, details on theoretical assumptions, the analytical process employed, and any peer review process were lacking. It did, however, highlight the OVO’s notions of the duty of a doctor, stating that clinicians need:
“understanding about not treating if not immediate and necessary until any charging and/or payment question is settled, as well as stabilising and discharging if necessary.”
Which bears a stark contrast to the GMC’s notions which affirms the duty of a doctor to “make the care of your patient your first concern”.
Focusing on Health Tourism, Creative research’s quantitative component, lauded as a “robust baseline estimate”, used country-specific immigration estimates extrapolated from the International Passenger Survey. Countries were then stratified according to levels of poor health economics and ease of access to the UK, with a percentage deemed “health tourists”. The authors acknowledge:
“We have had to stretch the data to make calculations that they were not originally designed for. We have also used a large number of assumptions, to some of which the results are markedly sensitive. There is a great deal of uncertainty in the results.”
Indeed, the degree of uncertainty is reiterated 65 times within the paper. With no rigorous evidence of intent, this limited evidence is pressed to arrive at an estimate of £70m/year (£20m to £100m). This contrasts with Doctors of the World’s findings, which found the average length of time in the UK prior to accessing services was 4.5 years. In addition, research conducted by UK HIV charity, the National Aids Trust, found that migrants tended to come to the UK unaware of their HIV status and testing happened, on average, five years later.
Despite criticism from The House of Commons Health Committee for previously trying to introduce similar changes “without any attempt at a cost-benefit analysis.” we cannot see that anything has changed. Evidence to justify such wide sweeping measures should be accompanied by a cost-benefit analysis taking into account the costs of administering the new system; diverting patients from normal access pathways; delayed diagnosis and treatment; and the cost to the economy of fewer migrants living, studying, working, and spending in the UK.
We strongly believe that if charging at point of care in A&E is introduced, operational and opportunity costs of missed early treatment will dwarf any savings from recouping treatment costs from migrants.
A regressive change that will worsen inequalities in health and access to healthcare
The proposed changes in eligibility for free NHS care are a socially regressive shift that will harm some of the most vulnerable and marginalised members of society. These include undocumented migrants, some victims of human trafficking, and refused asylum seekers not in receipt of section 4 or 95 support. They also include many people in poorly paid, highly insecure and stressful jobs, who are paying taxes and are making a significant contribution to the overall economic health of the country. The positive contribution made by the vast majority of non-permanent migrants is likely to outweigh any costs associated with receiving NHS healthcare.
The bureaucratic requirements for determining eligibility and immigration status will also deter certain eligible groups from accessing care in a timely fashion. As it stands evidence points to a deterrent effect of entitlement checks which negatively impacted on many vulnerable groups and pregnant women and children. There is substantial evidence that Black and Minority Ethnic (BME) communities experience poorer health outcomes associated with barriers to accessing health care, including institutional racism. Creating a culture in which eligibility is constantly questioned is likely to exacerbate this situation.
Contravening international Human Rights Obligations
The 1966 UN International Covenant on Economic, Social and Cultural Rights (ICESCR) provides for ‘the right of everyone to the highest attainable standards of physical and mental health’, and ‘the creation of conditions which would assure access to all medical services and medical attention in the event of sickness’. General Comment 14 on the ICESCR, further notes that:
“States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services; abstaining from enforcing discriminatory practices as a State policy; and abstaining from imposing discriminatory practices relating to women’s health status and needs”.
These proposals also seem contrary to the United Nations Convention on the Rights of the Child, (UNCRC), of which the UK is a signatory, which cements the right to health and requires that all children should be treated without discrimination; “… irrespective of their nationality, immigration status or statelessness.”
The government argues that these international agreements do not oblige it to provide free healthcare for so-called ‘illegal migrants’. However, notwithstanding any legal interpretation of international law, in a globalised world in which the UK extracts a disproportionate amount of wealth from poor countries (including a large number of trained health workers from poor countries), the denial of health care to ‘illegal migrants’ should be considered a breach of universal health rights on the basis of moral principles. Instead, the government’s proposals will only align the NHS to many unsubstantiated prejudices and xenophobic sentiments, which are harmful to society.
Undermining public health
Increasing barriers to accessing health services for large numbers of the most vulnerable members of society will undermine public health efforts to reduce health inequalities, ensure effective communicable disease control and prevent avoidable disease progression. Although free access to treatment for certain communicable diseases, HIV and sexually transmitted Infections will be retained, the proposed reduction in access to free healthcare will no doubt result in delayed diagnoses and treatment of even exempt diseases such as TB and HIV, both via the deterrent effect of changes and the reduction of free access pathways to review with significant adverse consequences to both patients and society in general.
For children, lack of automatic free access to health services affects the ability of services to identify issues related to child safety, health and wellbeing and thus the power of services to intervene. Moreover, the deleterious impact of decreased immunisation uptake on herd immunity has major repercussions for public health.
Undermining trust and professionalism
Under these proposals, health care providers may be required to act as quasi immigration officials – determining the immigration status of patients seeking healthcare. Apart from the costs involved, this will undermine trust in the profession as a whole, alter the ethical boundaries of healthcare providers and compromise the ability of health professionals to carry out their duty of making the care of their patient their first concern. Furthermore, the proposed creation of a legal gateway to share personal information relevant to charging for NHS services between the NHS, relevant government departments and other agencies raises serious and disturbing questions about the erosion of civil liberties, confidentiality and personal freedoms.See here for the refugee, asylum seeker and migrant access to care page