Festival of Debate: NHS – Free for All, Unless You’re A (Certain Category Of) Migrant

The NHS, Britain’s best loved institution, offering free healthcare to everyone, seems to embody the best of the UK. Except that sometimes it doesn’t. A panel debate discussed what this means for individuals and society.

Sarah Eldridge of City of Sanctuary Sheffield, painted a harrowing picture of the situation faced by refugees and asylum seekers. They are among the most vulnerable in society, often with physical and mental health problems arising directly from the situation they are escaping, their gruelling journeys here and how they are treated once they arrive. Asylum seekers have poor housing, they are given an allowance of only £5.28 a day, and they have to navigate the complexities of the immigration system, often with little knowledge of English.

The most vulnerable of all are failed – or refused – asylum seekers, who get no financial support, although the current 50% appeal success rate suggests the ‘failure’ is mostly by the Home Office. Since 2017 refused asylum seekers have had to pay, with some exceptions, for hospital and community healthcare upfront – even though they may not have any funding. Because the rules are so complex; along with the fear of deportation, language barriers and unsympathetic treatment by officials, even those who are entitled to free healthcare may not seek it. This means, for example, that a pregnant woman may not receive any antenatal care although payment for this is not required before receiving it: asylum-seeking women are three times more likely to die in childbirth than the general population.

Different NHS Trusts and individual staff interpret the rules in different ways. Kirsten Major, Deputy Chief Executive at Sheffield Teaching Hospitals, explained that the STH Trust interprets the rules as compassionately as possible, for example by ensuring that patients access free health care wherever possible. Decisions on charging are made by a separate team, so that doctors and nurses can make clinical decisions without taking charges into account. The Trust has a statutory obligation to charge where patients are not entitled to free health care and to share personal data with the Home Office if bills are unpaid. For those who are not entitled to free care, urgent and necessary care is provided without payment in advance, whilst elective care requires ‘up-front’ payment.

In Sheffield, charges account for a very small proportion of the Trust’s finances: STH issues around £500,000 worth of invoices a year, about 0.04% of turnover. While it was agreed that in some large London Trusts, the proportion would be much bigger, an obvious question is why it’s worth charging at all. On the other hand, when asked about this, Kirsten Major did say that the team making decisions costs less than the income from patients.

These points were underlined by Dr Jo Buchanan, a GP and volunteer for Doctors of the World, a charity working with vulnerable people in London. She described a recent experience when she was phoning a hospital about a patient and was asked for the patient’s status because they had recently arrived in the UK.  But it’s hard for non-experts to make a judgement, and patients may not receive free care even when they’re entitled to it. Dr Buchanan gave an example of a cancer patient who was refused treatment because he couldn’t pay. When Doctors of the World took up his case, with support from a solicitor, it was found that he was eligible for free care.

Dr Jeremy Wight, formerly Sheffield Director of Public Health, summarised public health implications of these policies – not surprisingly, all of them negative. Infectious diseases are not chargeable, but an individual may not know they have TB, for example, and so not seek help when they feel ill – and may not know they’re entitled to free care. Then the TB may deteriorate, which would of course be worse for the patient as well as costing the NHS more.

On a more general level, health inequality is a major public health issue affecting everyone, even the privileged. Easy access to care, via the NHS, improves population health as a whole. In addition, the culture of discrimination fostered by the regulations feeds into wider divisions within society. It becomes acceptable to say “no” to people rather than trying to help them. A member of the audience asked where our bravery has gone – not just in this context, but in other areas of the public sector. The culture of compliance affects us all, we’ve forgotten how to say “no” to regulations and do what we think is best. A doctor (bravely) spoke up to give an example of when he had worked against the system, but then in another case had not done so. Perhaps public sector workers are under so much pressure that it becomes more difficult to fight back?

Dr Wight went on to say that access to healthcare is a human right, and should not depend on contributions to society (through National Insurance etc). What happens to a congenitally ill child who certainly can’t contribute now and probably won’t be able to in the future: should they be denied care? Nor should it depend on legal status or nationality – which anyway are rarely challenged unless it’s thought someone could be an ‘illegal migrant’. Members of the audience emphasised how racialised healthcare is, and afterwards an American audience member said she’d never been asked to prove her status even though she has a ‘foreign accent’.

This affects NHS staff, too. Front-line staff’s attitudes to difference may be negatively affected by having to make decisions on status. Denying care to patients may also affect clinicians by forcing them to go against their code of ethics.

More broadly, the hostile environment around asylum seekers and refugees erodes trust and social values. Upfront payment for healthcare currently applies only to a few, easily targeted groups, but it could spread – what about smokers, obese people?

Also, common sense would support the argument of the practitioners on the panel and in the audience, that refusing free care for non-urgent cases can cost more in the long run. Community mental healthcare is chargeable, but it is surely more expensive, as well as most definitely inhumane, to deny free care to someone with mental health problems until they are so ill they need to be admitted to hospital compulsorily.     

All this led to two questions: How can we work with health professionals to make sure everyone can access the treatment they need? And how can we challenge a policy that denies people healthcare because they can’t pay?

STH emphasised information – sharing with patients, communities, health professionals and those who work with them, to make sure they know the rules and apply them fairly. Other examples of good practice included ways to help patients and practitioners negotiate the current system. There was discussion about how far you can stretch the rules or work within them (something that not only affects the health sector). An example is a pregnant woman who’s been subjected to FGM. She may have complications directly attributable to this, but it could be argued that pregnancy, while not arising from FGM, is harder because of it. However, some of the panel didn’t look convinced that this would fall within the rules.

Lobbying your MP can also have results. As if to prove this, on the day of the debate, the MoU between the NHS and Home Office, which required sharing of data if patients can’t pay their bills, was rescinded.  

The STH experience suggests that charging a few asylum seekers for some services is a small issue within the NHS; two employees said that they’d never heard about the Trust’s approach. But this debate made clear that it affects us all: Through the terrible treatment of vulnerable people and, more broadly, eroding the principles of the NHS and wider social values which everyone at the debate, if not everyone in the UK, subscribe to.

Words: Joanna Collins


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