Access to Healthcare for Vulnerable Groups
Confusion over entitlement has been a long standing problem with evidence supporting that even those entitled to free unhindered healthcare are not accessing it. A discussion of the rules of access to health and a justification of why universal coverage makes sense can be found here in a previous Migrant’s Rights Network blog and briefing.
BMA Guidance for doctors: Access to health care for asylum seekers and refused asylum seekers
Despite this the government have set in motion changes which will only serve to make the situation worse.
The Immigration Act
The aspects of the proposals that have been carried forward to being proposed as primary legislation can be found within the Immigration Act that came out in October. This Bill will go through the stages outline on the UK Parliament website. There are two key parts of the Act that will impact on health:
Introduction of the Immigration Healthcare Surcharge (Chapter 2, Clause 33)
Instituting an annual healthcare surcharge for ‘temporary migrants’ from outside the EEA which will be payable on Visa application. This is purported to be in the region of £150-200.
Changing the definition of ‘ordinarily resident’ (Chapter 2, Clause 34)
The proposed change will the current case law definition of ‘ordinary resident’ from those that are deemed to be living in the UK for a settled puspose to only those who have been granted ‘indefinite leave to remain’ (ILR). A status that the Department of Health reports takes on average five years. Consequently, many non-EEA documented migrants’ including students, workers and newly arriving family members of existing UK citizens will have restrictions placed on access and will become chargeable.).
The Immigration Bill gained Royal Assent on 14th May and is now the Immigration Act 2014. Its progress through the horses of Parliament can be viewed on the UK Parliament website.
The Broader Programme of Changes
At the end of 2013, the Government announced its intention to implement charging, for those without “indefinite leave to remain”, for emergency services and most areas of primary healthcare services, although GP consultations will remain free of charge. They outlined a four phase plan:
Phase 1: Improving the current system of identification and cost recovery
As part of their wider plans the government also intends to develop more effective ways of claiming reimbursement from EEA member states for the treatment of its nationals within the NHS whilst maintaining their free access to services.
Phase 2: A new registration system
The proposals also outline plans to develop a new system aimed at identifying people’s immigration status at point of access. Including the possibility of immigration status corroboration being required to register at the GP. In their words, to establish “a legal gateway to formalise the sharing of personal information relevant to charging for NHS services between the NHS, relevant government departments and other involved agencies.”
Phase 3: The health surcharge
Now the Immigration Act 2014 has been given Royal assent the Home Office will draft regulations as to its implementation.
Phase 4: The Extension of Charges
After the Immigration Act 2014 has allowed for the inclusion of migrants who could have qualified for free treatment under the ordinary resident test. Ammendments will be made to legislation, including to the National Health Service (Charges to Overseas Visitors) Regulations 2011:
• To amend charging to include primary care (except GP consultations)
• To amend charging rules for dentistry, optics and pharmacy
• To amend charging to include A&E
• To amend charging rules to ensure all commissioned providers of NHS care (NHS and non-NHS organisations) can charge.
Implications for Primary Care
- GP consultations (or their equivalent) will remain free
- Primary care outside of a GP consultation (or equivalent) will be chargeable
Implications for Secondary Care
- Care given and medicine received in A&E will be chargeable when charging is practicable. We will work with the NHS to ensure this happens at the right time.
- Care given and medicine received in Minor Injury Units will be chargeable when charging is practicable.
- NHS-funded care provided by non-NHS providers (e.g. voluntary or independent sector) will become chargeable.
Other Care Settings
- Exemptions for free treatment for visitors and migrants in certain categories (e.g. over 60s) may be removed for dentistry, optics and pharmacy; or all treatments in these settings may become chargeable.
- Further consideration will be given as to how elective mental health services are charged for under the current rules and whether charging may be extended to services.
- There is a possibility of charging for some family planning services (e.g. Termination of pregnancy, IUDs and oral contraceptives). Though there is the assurance given that all sexual health services will however remain free.
- NHS care given in the community will be chargeable where charging is practicable and not detrimental to public health.
- Care given by NHS Walk-In Centres may become chargeable.
Further details on the implementation plan can be found here.
Alma Mata’s Work
We feel that the consultation and the ensuing Immigration Bill needs a strong response on public health, economic and humanitarian grounds. What is being proposed could also radically affect healthcare professionals’ relationship with their patients.
Alma Mata has been working with Medact, Doctors of the World, Migrants’ Rights Network, the Terrence Higgins Trust, The National AIDS Trust, Still Human Still Here, Medsin and other organisations as part of the Entitlement Working Group. There is website outlining responses to the consultation and useful resources to help formulate responses to the proposed changes.
Please see the Alma Mata Global Health Network Working Group’s response to the Government’s Consultation on Migrant Access to the NHS. Alma Mata Response to the Government Consultation on Migrant access to the NHS
The government in parallel with this consultation commissioned “research” to accompany the bill. The results of which were, unfortunately, unavailable at the time of submission of responses for the consultation. This research was released along with the following government press release. There is an interesting Guardian trail that highlights some of the key issues that have been identified with this research.
Alma Mata’s Contribution to Committee Stage
Alma Mata has been involved in submitting evidence to the Public Bill Committee both as a member of the Entitlement Working Group and as individuals.
The Entitlement Working Groups evidence can be found below.
Several members of Alma Mata submitting separate evidence to the Public Bill Committee stating that:
1. On 29 October, the Immigration Bill Committee heard evidence from Professor Meirion Thomas of the Royal Marsden Hospital.
2. We are all doctors who are working or have recently worked for the NHS in London. We would like to state that the term “Lagos Shuttle” is not a term that is commonly used by NHS staff. Moreover, to our knowledge, none of us has encountered a so-called ‘health tourist’ – an overseas visitor travelling to the UK for the purpose of accessing NHS services – in the course of our clinical duties.
Alma Mata Lancet Global Health Blog Post
In the wake of proposals to radically reduce migrants’ access to England’s National Health Service (NHS), we question how much consideration has been afforded to the wider public health implications of these proposals, and to what extent they are evidence-based, cost-effective, or even safe.
Other Publications to Read
Doctors of the World – London Clinic
Praxis, Pott Street, London E2 0EF. Tel: 020 8123 6614
Mobile: 07974 616 852
Open every Mon, Wed and Fri 1-5pm. No appointment necessary.
Doctors of the World runs a clinic and advocacy programme in east London that provides medical care, information and practical support to vulnerable people, helping them access the healthcare they need.
The clinic is run by volunteer doctors, nurses and support workers who provide information and basic short-term healthcare to excluded people across the UK, such as vulnerable migrants, sex workers and people with no fixed address
Freedom from Torture
111 Isledon Road, London N7 7JW.
Tel: 020 7697 7777; Fax: 020 7697 7799
Provides services for survivors of torture and other forms of organised violence. Centre staff carry out casework, counselling, advice regarding welfare rights, physical and mental health care, individual and group therapy, complementary therapy, family therapy and child and adolescent psychotherapy. They also give advice, help with the access to statutory health care and write medico-legal reports at the request of solicitors. Staff run training sessions and workshops for professional groups working with refugees and survivors of torture and can discuss issues with health care workers. There are five centres across the UK and details on these are available on the website.
Helen Bamber Foundation
5 Museum House, 25 Museum Street, London WC1A 1JT
Tel: 0207 631 4492; Fax: 0207 631 4493
Human rights organisation that provides treatment and support to survivors of torture, war, genocide, human trafficking for sexual exploitation or labour, gender based violence and extreme domestic violence. Along with Freedom from Torture they are a principal centre for assessment of the sequelae of torture and write medico-legal reports on referral from legal representatives and doctors.
240-250 Ferndale Road, Brixton, London SW9 8BB.
Tel: 0808 808 2255 or 0808 808 2259 (text phone)
The Refugee Council runs a mixture of direct and indirect services for refugees and asylum seekers in the UK. The main services include the One-Stop Service available in London, Yorkshire & Humberside, East of England & the West Midlands.
Scottish Refugee Council
5 Cadogan Square (170 Blythswood Court), Glasgow, G2 7PH
Tel: 0141 248 9799; Fax: 0141 243 2499
Welsh Refugee Council
Phoenix House, 389 Newport Road, Cardiff, CF24 1TP
Tel: 029 2048 9800; Fax: 029 2043 2980
Experiences of Gömda in Sweden: Exclusion from health care for immigrants living without legal status – Results from a survey by Médecins Sans Frontières
GPs must not be the new border agency in policing access to the NHS: RCGP reaction to Queen’s speech
May 2013 statement by Royal College of General Practitioners Chair Dr Clare Gerada, saying GPs have a duty of care to all people seeking healthcare and should not be expected to police access to health care. This is based on a previous position statement.
Access to Health Care for Asylum Seekers and Refused Asylum Seekers – guidance for doctors
The Ethics Department of the British Medical Association issued this advice in 2012. Covers all the main issues and ends with contacts for further advice – and is only 12 pages!
IHU Entitlement Report 06(Opens a PDF file)
The identification and charging of Overseas Visitors at NHS services in Newham: a Consultation was a consultation carried out in 2005-6 by Imperial College for Newham PCT to investigate the then charging procedures at hospital and primary medical services and which ‘speculatively explore[d] the likely impact of the primary care proposals’. They used the Health Impact Assessment framework. Detailed and still very relevant.
Healthcare for the Community’s Most Vulnerable – Project London Report
Hanefeld J, Horsfall D, Lunt N, Smith R. Medical tourism: a cost or benefit to the NHS? PLOS ONE. DOI 10.1371/journal.pone.0070406
Making Children Pay for Their Healthcare Poses Significant Risks – The Children’s Society
NHS Choices. The Principles and Values of the NHS in England.
King’s Fund. How should we pay for healthcare in future? Results of deliberative events with the public. The King’s Fund.
Marmot, M. Fair society, healthy lives: the Marmot Review: strategic review of health inequalities in England post-2010. Marmot Review. 2010.
BBC News Health. NHS told to do more to ‘reduce health inequalities’. BBC. 18th March 2013.
Crawley, H. Child First, Migrant Second: Ensuring that Every Child Matters. Immigration Law Practitioners’ Association, London, 2006
Lengar, S and LeVoy, M. Children First and Foremost – A guide to realising the rights of children and families in an irregular migration situation. Platform for International Cooperation on Undocumented Migrants. 2013.
Council of Europe. Undocumented migrant children in an irregular situation: a real cause for concern. Council of Europe committee on migration, Refugees and Population, Doc. 12718, Strasbourg, 16 September 2011, page 5.
Reeves M, de Wildt G, Murshalie H, et al. Access to healthcare for people seeking asylum in the UK. Br J Gen Pract 2006; 56: 306-08.
Williams PD. Failed asylum seekers and access to free healthcare in the UK. Lancet 2005; 365: 1767.
Harris R. The Exclusion of Failed Asylum Seekers from Free NHS Care: a Policy Analysis and Impact Assessment. International Health BSc Dissertation. London: UCL, 2005.
Cutler S (Based on the report by: Hargreaves S, Cook J, Médecins Sans Frontières. The health and medical needs of immigration detainees in the UK: MSF’s experiences). Fit to be detained? Challenging the detention of asylum seekers and migrants with health needs. BID: London, May 2005.
Romero-Ortuno R. Access to healthcare for illegal immigrants in the EU: should we be concerned? Eur J Health Law 2004; 11: 245-72.
British Medical Association. (2002) Asylum seekers: meeting their healthcare needs. London: British Medical Association
Burnett A, Peel M. Asylum seekers and refugees in Britain. BMJ 2001; 322: 485-88.
Kelley and Stevenson. First do no harm: denying healthcare to people whose asylum claims have failed. Refugee Council, 2006. Available from
Borman E. Health Tourism. BMJ. 2004;328:60–61
Bhatia, R; Wallace, P. Experience of refugees and asylum seekers in general practice: a qualitative study. BMC Family Practice 2007; 8 (48)
Cowen, T. Unequal Treatment: findings from a refugee health survey in Barnet. London: Research Health Access Project. 2001
Greater London Authority. Department of Health Consultation “Proposals to Exclude Overseas Visitors from Eligibility to Free NHS Primary Medical Services”. Response by the Mayor of London. London: GLA, 2004.
Department of Health. Giving all children a healthy start in life. Department of Health 2013
NICE . Reducing differences in the uptake of immunisations (including targeted vaccines) among children and young people aged under 19 years. National Institute of Clinical Excellence. 2009.
HSCIC. MMR vaccine: coverage for young children by age two at highest level in 14 years. Health Social Care Information Centre, 2012.
Chief Medical Officer letter on rising levels of measles. April 2013. Available here:
Greenaway, C., Dongier, P., Boivin, J.F., Tapiero, B., Miller, M. & Schwartzman, K. Susceptibility to measles, mumps, and rubella in newly arrived adult immigrants and refugees. Ann Intern Med, 2007;146, 20-4.
Lynch, M. A. & Cuninghame, C. Understanding the needs of young asylum seekers. Arch Dis Child, 2000; 83, 384-7.
Leveson and Sharma. The Health of Refugee Children: Guidelines for Paediatricians. London: King’s Fund and Royal College of Paediatrics and Child Health, 1999
Allen G. Early Intervention: The Next Steps; an Independent Report to Her Majesty’s Government by Graham Allen Mp: The Stationery Office; 2011.
Field F. The Foundation Years: preventing poor children becoming poor adults: The Stationery Office/Tso; 2010.
Tickell C. The Early Years: Foundations for life, health and learning. London: The Stationery Office; 2011.
Every Child Matters – A Change for Children http://www.ukba.homeoffice.gov.uk/sitecontent/documents/policyandlaw/legislation/bci-act1/change-for-children.pdf?view=Binary
Saving Mothers Lives Confidential Enquiry into Maternal Death 2003-2005 (2007) www.publichealth.hscni.net/publications/saving-mothers-lives-2003-2005
Lewis G, Drife J. Why mothers die 2000-2003: Sixth report of the Confidential Enquires into Maternal Deaths in the UK. London: Royal College of Obstetricians and Gynaecologists Press/CEMACH 2004.
Medact. Maternal and infant health of vulnerable migrants. Medact. January 2008.
Health Inequalities Unit, Department of Health. Review of the Health Inequalities Infant Mortality PSA Target. Feb 2007.
Project: London. Improving Access to healthcare for the community’ s most vulnerable: Report and Recommendations 2007. London: Medecins du Monde. 2008.
Project: London. Helping vulnerable people to access healthcare: Report 2006. London: Medecin du Monde. 2007.
House of Lords, House of Commons, Joint Committee on Human Rights. The treatment of asylum seekers: tenth report of session 2006–07. Volume II—Oral and Written evidence
National AIDS Trust. Independent Asylum Commission: Evidence from the National AIDS Trust. London: National AIDS Trust. 2007
Lyall H, Tookey PA. Low rates of mother-to-child transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000–2006. AIDS 2008; 22: 973– 981.
M Redshaw, R Rowe, C Hockle, P Brocklehurst – Recorded delivery: a national survey of women’s experience of maternity care, 2006
Amnesty International and Southall Black Sisters. ‘No Recourse’ No safety – The Government’s failure to protect women from violence. Amnesty International, 2008
Lewis and Drife (2001, 2005); McWilliams and McKiernan (1993), cited by Women’s Aid Federation of England, Statistics: Domestic Violence.
The National AIDS Trust. (2008). The Myth of HIV Health Tourism. NA