03/10/2016

Barriers to Healthcare for Refugees and Migrants Living in the UK
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
How the NHS is failing a vulnerable demographic.

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Image By Karim Chraihi
   

The hardships faced by modern day refugees seem to form an unending list, yet while these prisoners of geography display outstanding resilience and bravery, the Western world continues to play the role of bystander and watch passively as innocent people are reduced to the collateral damage of war.  As of late, the media has begun to portray a mood of international support through the simple message of “refugees welcome”, which begs the question, why is it that for thousands, the struggle for a better standard of living does not end upon their arrival to the UK? 

The stark reality is that undocumented migrants experience a myriad of barriers that deny them the medical attention they need.The NHS at its core stands for universal entitlement to primary care, emergency care and treatment of infectious diseases[1]. But the statistics do not reflect this; 94% of patients attending a Doctors of the World (DOTW) clinic in East London have been unable to register with a GP, despite having lived in the UK for an average of six years[2]. A small group of doctors and support workers provide an extraordinary voluntary service for homeless people, drug users, sex workers, victims of trafficking, refugees, asylum seekers and undocumented migrants – the individuals that collectively form the most vulnerable demographic in our population. In a few small rooms in Bethnal Green, these volunteers help individuals overcome the ever-increasing barriers to UK healthcare access faced by those living on the margins of society. However, within our healthcare system, there should be no need for organisations and clinics such as this in the first place. Nor should there be disparities between the quality and level of healthcare received by non-migrant and migrant individuals. Even so, a recent report found that only 1/3 of pregnant migrant women had their first antenatal consultation in the first trimester of pregnancy compared to 3/4 of non-migrant women in England – a shocking statistic considering the NHS’s standpoint on providing necessary and immediate antenatal care to all pregnant individuals[3]. 

As a clinic support worker for Doctors of the World, a medical student and someone who has dedicated a considerable part of their life to working with displaced individuals, I am too often appalled by the failures of our NHS to meet the needs of people with multiple vulnerabilities. In the clinic my role is simple: to help users access the main-stream services to which they are entitled. Unfortunately, bureaucracy and case complexity obstruct this supposedly simple and easy access to healthcare for all, and add to the mounting list of barriers which put it out of reach. Ultimately, I have witnessed this shortfall result in the children of undocumented migrants being unable to receive essential immunisations; a pregnant woman who has not sought antenatal care in 19 weeks, for fear of being reported to the Home Office; a victim of human trafficking suffering from renal failure kept off the waiting list for an organ transplant due to his pending immigration status; and a distraught woman who had been billed £6000 for maternity care even after her baby had died. 

A lack of formal documentation, in the form of ID and proof of address, is often referred to as the principle reason refugees and asylum seekers are turned away from GP practices. However, this has no legal basis because these documents are not necessary for registration.This is reflected very clearly at the DOTW clinic: 29% of service users cite administrative or legal barriers and 17% a lack of knowledge about individual rights as reasons for not getting medical attention. Shockingly, there have even been instances in which GP practice managers have instructed their administrative team to turn away anyone without British citizenship. Unfortunately, children are not spared the obstacles to healthcare faced by adults, thus resulting in potentially dangerous failures to safeguard young people. As a nation, we are overlooking the most vulnerable members of our population and it is to our own detriment. 

Widening access to healthcare is key to maintaining population health and simultaneously cutting costs within the NHS. Prevention of further health complications through implementing antenatal care and childhood immunisations to these marginalised population groups protects individuals and communities. At the same time, the cost of providing late effective secondary care services to treat complex presentations can be avoided with earlier and more efficient detection and treatment. Healthcare professionals have been misled into acting as immigration enforcers, when they should be invested first and foremost in the safeguarding of people’s health. 

The NHS is often praised for its adherence to the values of universality, equality and high quality care.Yet it is this same organisation which, since the Immigration Act of May 2014, has been working to make it “more difficult for illegal immigrants to settle in the UK and in April 2015, brought in a £200 per year healthcare surcharge for those seeking to stay in the UK for over six months”[4].  Individuals living outside the European Economic Area without personal health insurance began to be charged 150% more than the cost of their NHS treatments[1].The definition of an “ordinary resident” was also changed such that anyone without indefinite leave to remain in the UK would be subject to the charge[2].The introduction of the Migrant andVisitor NHS Cost Recovery Program saw the Department of Health aim to expand the scope for profit and to identify more chargeable patients[5]. The NHS has been rapidly changed to mirror our society - one set on profiting from the plight of individuals who have already experienced unfathomable hardship. 

Irrespective of politics and bureaucracy, it is painstakingly clear that healthcare infrastructure, both nationally and internationally, requires urgent repair to reduce barriers to medical access for marginalised populations.This by no means involves ceasing to charge for healthcare altogether - that would be foolishly unsustainable. Individuals who are liable to charges and have the means to pay should do so. However, we cannot continue to put vulnerable people at risk of serious harm as a result of the current and proposed policies denying them access to vital services.This suffering is avoidable and inexcusable. Healthcare professionals have a professional duty to all of their patients, regardless of their immigration status. Much more needs to be done to help protect dispossessed people from the innumerable threats they face. It is only through tireless advocacy that we can bring about policies and practices that support robust healthcare provision for all. 

By Nazanin Rassa
MBBS Year 3, intercalating in Global Health 

  1. NHS entitlements: Migrant health guide. (n.d.). Retrieved August 12, 2016, from https://www.gov.uk/guidance/nhs-entitlements-migrant-health-guide
  2. Doctors of the World (August 2015) Access to Healthcare in the UK (Rep.). London, Doctors of the World UK.
  3. Shortall, C et al (2015), Experiences of Pregnant Migrant Women receiving Ante/Peri and Postnatal Care in the UK: A Doctors of the World Report on the Experiences of attendees at their London Drop-In Clinic
  4. Immigration Act: Overview. (n.d.). Retrieved August 12, 2016, from https://www.gov.uk/government/publications/immigration-bill-2015-overarching-documents/immigration-bill-201516-overview-factsheet
  5. SER/NHSCRP/13790. (14 July 2014). Visitor & Migrant NHS Cost Recovery Programme: Implementation Plan 2014-16 (pp. 1-70) (United Kingdom, Gov.uk, Department of Health). gov.uk.


CASE STUDY 

Zachary, 17, from Somalia 

Zachary had been living undocumented in London with his mother and four siblings since 2007. In early 2015 he began to experience mild headaches, for which his GP prescribed migraine medication. His pain persisted and he was rushed to A&E where he was diag- nosed with meningitis. 

Weeks after his recovery, Zachary’s mother, Sofia, received bills of over £5,000 for her son’s treatment. “‘They said we needed to pay the money immediately. If we failed to pay, they would take us to court, add charges and even send [the matter] to the Home Office.” 
Terrified and unable to pay, she turned to DOTW for help.“It was only when I came [to the clinic] that my mind was a little bit better.They promised me they’d try their best to find a solution.”
DOTW volunteers took up the case with the knowledge that Sofia’s bill was completely unjustified, as meningitis is a condition specifically excluded from charges. Subsequently, the charges were cancelled within days. 

Targeted public health control measures need to be instituted rapidly in order to prevent the spread of meningitis due to its infectious nature and life-threatening severity. According to the Immigration Act, undocumented migrants are allowed to access certain secondary services under the NHS.This includes treatment for some infectious diseases, such as measles or tuberculosis, as well as urgent life- threatening conditions. In Zachary’s case the treatment was for meningitis, which falls under both of these criteria for free access to secondary care, hence, payment for his care should not have been requested. 

2015 Case Study from DOTW UK 
Testimony collected by Guardian journalist Jan 2016 
Case study written by Laurane Lewis Jan 2016

CASE STUDY 

Josephine, 37, from Uganda 

Josephine fled Uganda because of her sexuality. She had been “forced into marriage because they found out I was gay which is not allowed in my country”. Her husband had abused her after he found out about her sexuality and told her family. Josephine was forced to go into hiding with her friend, leaving her children behind.  She was “scared he would have revenge on me because he said I brought disgrace to the whole family. I feared for my safety”.

Through an agent, Josephine was able to obtain a visa for the UK and took a flight here without knowing what to expect on arrival. “I just knew it would be a country far away from mine and that nobody would know me and nothing would happen to me and nobody was going to harm me.”

Josephine was 27 weeks pregnant when she arrived in the UK. Soon after arriving in London, she was taken in by another Ugandan woman whom she had met at a bus stop. “I started to beg her, my feet were swollen and I had been walking up and down for 2 days, I hadn’t showered and I hadn’t eaten well”. She was still staying with this woman when she visited the clinic. Despite constant reminding by friends that accessing healthcare in the UK was “tough”, Josephine tried to register with a GP three times. “Every time they would chase me away, they told me that as my visa was still valid I wasn’t entitled and that if we work on your you’re going to have to pay. They told me I would have to pay something like £300.” She was 35 weeks pregnant by the time she had her first antenatal appointment at a hospital, arranged by DOTW.  After her first appointment she “thought that as they had given me another appointment everything was fine, but after some time they sent me a bill. The bill was for £329.”

Josephine’s application for asylum was denied. “I’m waiting for the court date for appeal next month to see if they will grant me asylum. I have to go to the home office every month to report. I don’t want to think about what’s going to happen; I’m just living each day as it comes at the moment”.

She has now had her baby and is registered with a GP as a temporary patient, meaning that she is able to access free healthcare by re-registering every other month. She is still staying with the same woman in a cramped, one-bedroom house as her application for help with accommodation was denied. “She initially said to me that since I’m going to have a child of my own this place won’t be big enough for all of us. She already has a son. There are four of us living there. It’s hard, but there’s no other choice at the moment and it’s better than being out there. At least I feel free here and I don’t expect that anybody would harm me here, which wouldn’t be the case back there. I can walk around freely which I couldn’t do there after I left my husband“.

Public health issues raised:
Asylum seekers are one of the most vulnerable groups within our society. Within this group are individuals more vulnerable still, including pregnant women (like Josephine), unaccompanied children and victims of torture.
GPs can only refuse to register patients if the patient lives outside their catchment areas or their list has been closed (in agreement with NHS England). They also must not discriminate on the grounds of race, religion, age, sex, sexuality or disability. Guidance from NHS England states that no person in the UK, regardless of residential or immigration status, should be prevented from registering with a GP because they are unable to provide proof of ID or address.

2015 Case Study from DOTW UK 
Testimony collected and case study written by Sarah (Team Up volunteer), Jan 2016