What price are NHS health professionals willing to pay for a more ‘affordable’ service?
On Monday 23rd October the Department of Health will extend charges for NHS treatment that will exclude refused asylum seekers from some essential services and create more barriers for many other vulnerable groups in society.
The inhumanity of introducing a charging regime for some of the most vulnerable people in our society, many of whom have fled war, famine, and persecution, has quite rightly been highlighted. The potential these changes have for harming people’s health is huge, including depriving people of life-saving treatment, allowing conditions to worsen due to treatment delays (not to mention increasing costs), and the possibility of a public health risk due to untreated infectious disease. But as well as the moral and ethical issues raised by these changes, there are issues for NHS staff, and I’m going to address them here.
The Government wants to create a ‘hostile environment’ for migrants. Except this time it is NHS staff, not UK Border Police, who are doing the immigration checks. Despite Government protestations, it seems increasing likely the new Regulations will involve frontline NHS staff, a fact acknowledged by the independent Government review of the changes. What is more, the NHS will now provide information to the Home Office about immigration status under a new data sharing agreement.
Though a pilot scheme has run in 20 UK hospitals, limited information is available about its success. Issues raised during pilots included treatment delays for eligible patients, confusion about immigration status, and suspicions of racial profiling. Hospitals have been given additional administrative support during the pilot, but whether this is available for the rollout is unclear. What does seem sure is the increasing involvement of clinicians. Deciding whether a treatment is urgent or ‘immediately necessary’ is crucial to upfront charging – if a treatment is deemed either of these, then it should be given irrespective of ability to pay. This is a clinical decision, not an administrative one, and thus requires the input of frontline NHS staff.
As a doctor I fundamentally object to being involved in these decisions. My job is to assess and treat patients on the basis of need, not immigration status. I have a personal and a professional duty of care to patients to “show respect for human life”. In the chaos that so often reigns during an on-call shift, NHS staff do not need additional confusion about whether they’re allowed to treat patients. They already face ever-increasing pressures. Not only that, if we fail to treat eligible patients because of confusion about immigration status we may in breach of the Human Rights Act. To add insult to injury, NHS staff who provide treatment to patients who cannot pay may face disciplinary action.
Immigration checks in hospital are not only morally questionable, they’re also not workable. A survey of healthcare professionals published today by Medact Manchester shows that NHS staff do not even understand the distinctions between refugees, asylum seekers, and ‘failed’ asylum seekers (the definition used by the Government), let alone be able to determine which groups are actually eligible for care. Worryingly, two-thirds of NHS staff responding to the survey thought that ‘failed’ asylum seekers were not eligible for free primary care, with a further third thinking they were not eligible for emergency treatment through A&E. Both primary care and emergency care are exempt from all charges under the Regulations, irrespective of immigration status.
This lack of knowledge did not appear related to encounters with asylum seekers. Over half of our survey responders said they had treated a survivor of torture. However, only one in ten were confident in documenting torture, and a quarter said they may avoid asking about torture as a result. This has huge implications for the new legislation, as survivors of torture are exempt from paying for some treatment. If NHS staff are unable to ask about and appropriately action torture, they may be inadvertently denying people treatment that they desperately need, or forcing people to pay for treatment that they cannot afford.
Extending soft borders into the NHS undermines the principle of confidentiality central to the clinican-patient relationship. If the Home Office can access patient data, patients will be deterred from seeking help they urgently need for fear of affecting their immigration status, as happened during the Grenfell Tower tragedy.
NHS staff are not competent to assess someone’s eligibility for treatment. They are clinicians, not immigration officers. In no time during my 15 years of medical education have I been taught how to check someone’s passport. We have a legal, professional, and moral obligation to resist these changes. We’d all like a more affordable NHS, but not at any cost.