Regional Asylum Activism Briefing
Free Access to Healthcare for
People Seeking Asylum
What’s the Problem?
People seeking asylum have been forced to flee their home countries – places like
Syria, Iran and Somalia – due to conflict and persecution. Many arrive in the UK after having been threatened, detained, beaten or tortured. The UK has signed up to the Refugee Convention, and people who claim asylum here are exercising a legal right to seek protection from persecution.
Due to their experiences in their country of origin, their perilous journey to safety and their experience of claiming asylum in the UK, some people seeking asylum have multiple and complex health needs. It is crucial that they are able to access the healthcare they need regardless of their immigration status.
People in the asylum process experience significant and multiple barriers to accessing the healthcare that they need. This ranges from facing discrimination when registering with GP practices, to facing high financial charges for certain elements of healthcare if they are refused asylum.
We are committed to ensuring that anyone who claims asylum in the UK has free access to healthcare whilst they remain in the country and continue to state their case for a safe haven from persecution.
Refugees, Asylum Seekers and the National Health Service
Refugeesare treated as resident British nationals as soon as they receive leave to remain in the UK. They are therefore entitled to free healthcare at all levels of care.
Anyone who has lodged a formal request for asylum in the UK is also exempt from all charges, whilst the asylum seekers’ application is still in process or any appeal is pending.
Refused asylum seekers are still entitled to free primary and emergency healthcare. For those who have had their application refused or are not in receipt of some form of statutory support (Section 4 and Section 95, Section 21 of the NAA, or if they are a child who is looked after by a local authority),charges apply for secondary healthcare(i.e. non-emergency hospital treatment). This only came into force in 2009 following a Court of Appeal judgement.
Chargeable patients are not charged for the continuation of treatment that started when their claim was in process. A refused asylum seeker who is later recognised as being in need of some form of protection should have the charges repaid or, if still pending, these charges should not be recovered.
However, treatment should never be denied if an individual’s condition requires urgent or immediately necessary care (includes all maternity care). Clinicians are responsible for deciding the urgency of treatment, not the staff administering charges.
Why Are We Worried?
Whilst according to current legislation, refugees and people seeking asylum in receipt of Home Office support are able to access free healthcare in the UK, research has shown that despite this entitlement, many face particular barriers in accessing primary care. Equally, some people who have had their asylum claims refused are chargeable for secondary care (mainly care provided in a hospital setting). We are increasingly concerned that refused asylum seekers who are not in receipt of Section 95, Section 4 or any Local Authority support will be unable to access the healthcare that they need.
Equally, the Immigration Act 2014 contains a number of provisions which could change the eligibility criteria for access to free healthcare in England. It paves the way for charging anyone who does not have indefinite leave to remain in the UK for some primary and any emergency care they may require. Whilst we welcome the continued exemptions for refugees and people seeking asylum on statutory support, we are concerned that these changes will increase confusion over entitlements and will lead to vulnerable people being denied access to primary healthcare because they cannot prove entitlement, do not qualify, or are wrongly refused access.
We believe that proposals to extend charging procedures to parts of primary care (consultation with GPs and nurses would remain free) and all emergency care will put the health and wellbeing of those seeking safety from persecution at further risk, and will also carry risks for the health of the wider public. We also believe that the changes to NHS procedures outlined by the Department are unworkable, under-researched and unwelcome.
Key Arguments to Support the Call for Free Access to Healthcare for People Seeking Asylum!
The arguments below outline why people seeking asylum should not be charged for healthcare while they remain in the UK. Some arguments relate to the current system (which charges refused asylum seekers who are not in receipt of statutory support for secondary healthcare), and some relate to proposals to extended that charging to primary and A&E care.
1. Just Because Someone Is Refused Asylum, It Does Not Mean That They Do Not Have A Protection Need
1.1 There are many reasons why someone who has received a refusal on their asylum claim may remain in the UK. Unreliable decision making by the Home Office combined with a lack of good legal advice can mean that many people reach the end of the asylum process without their protection needs being recognised. Roughly 50% of all asylum applicants do receive some form of leave to remain in the UK. Please see our briefings on destitution and poor decision making for further information.
2. People in the Asylum Process Can Have Complex and Multiple Health Needs
2.1 Some migrants and asylum seekers have particular healthcare needs. For example, the Royal College of Psychiatrists has noted that “the psychological health of refugees and asylum seekers currently worsens on contact with the UK asylum system”, whilst the Royal College of Obstetricians and Gynaecologists also reported that asylum seeking women are three times more likely to die in childbirth than the general population. The current confusion over entitlements - along with the proposals to extend charging procedures - will deter many vulnerable individuals from accessing preventative care through primary healthcare. This will have a personal cost to the health and wellbeing of the individual and a financial implication for the NHS through the mounting costs of delayed treatment.
2.2 People seeking asylum are also vulnerable to significant mental health challenges. These may include post-traumatic stress disorder, severe depression, and anxiety. This is often exacerbated by feeling a lack of control over their circumstances (having no choice over where to live, no right to work, and risk of destitution); and separation from culture, language, family and friends, which means their usual avenues of emotional support are unavailable. It is important that those suffering from mental health challenges are able to access preventative, early-intervention care without fear of charges.
2.3 The experience of destitution alone can adversely affect the health and wellbeing of people in the asylum process. A 2012 report on the health needs of homeless individuals in the UK found that being homeless for even a short period of time increases the risk of long term health problems. Equally, asylum seekers and refugees are among the highest risk categories for suicide in the UK. It is crucial that these vulnerable individuals are able to access the care that they need.
3. Increasing Barriers to Healthcare Puts Public and Personal Health at Risk
3.1 Those in the asylum system already face significant barriers to accessing healthcare in the UK. Doctors of the World reported in 2012 that 73% of the patients they saw in London were not registered with a GP even though they were eligible. Approximately 20% stated that they did not seek care because they were afraid of being reported to the authorities and being arrested. Research carried out by United for Change in Salford found that 63% of asylum seeker participants found the process of registering with a GP not very easy or not at all easy.
3.2 Any charging system discourages vulnerable groups from accessing healthcare, even when they are entitled to free treatment.This applies to the current system and to the proposals to extend charging to primary and emergency care. This is because individuals either have difficulties proving entitlement, they are wrongly refused access to healthcare, or because they do not try to access the system because they fear they will be charged. This does not just affect asylum seekers and refugees; vulnerable British residents (the homeless and those with mental health problems) will also be deterred from accessing healthcare if asked to prove their immigration status before accessing care.
3.3 GPs are the most common referral route for the diagnosis and treatment of infectious diseases and mental health issues, as well as for accessing maternity services. Whilst the treatment of communicable diseases is currently exempt from charges, individuals will still have to present themselves at GP surgeries in order to have their symptoms diagnosed. Uncertain about the nature of their condition, and fearful of incurring high financial charges, many do not access preventative care at a primary healthcare level, therefore increasing the risk of infectious and communicable disease throughout the community. Current barriers experienced by people seeking asylum in accessing GP services already results in missed screening tests and late treatment; creating adverse impacts for their own health and that of the wider community. This would only increase if proposals to extend charging to primary care are progressed.
3.4 GPs also represent an important gateway to welfare and support for people seeking asylum (for example when a person applies for S4 support on health grounds they must get a letter from their GP). They are also an important source of information that can determine how a person is treated at various points in the asylum process (for example, if a person has serious mental health issues they should not be detained). It is vital that GPs have an awareness of this responsibility.
4. Limiting Access to Preventative Care is Costly for the NHS and Creates Negative Health Outcomes forVulnerable Individuals
4.1. If individuals are fearful of accessing healthcare for minor ailments due to charging procedures, conditions can often worsen into more chronic, hard to treat cases. According to the British Medical Association and the Royal College of Nursing, this could result in general delays to treatment until conditions deteriorate, forcing individuals to present at A&E.
4.2 Providing emergency healthcare for advanced medical conditions is far more expensive than the provision of preventative care. In Northern Ireland, where a charging system already operates, a refused asylum seeker who could not get access to an inhaler for her asthma needed to be admitted to a Belfast hospital. The cost of a prescription would have been £12. Instead, the visit to A&E by ambulance and five days in hospital cost £1,508. Considering the existing strain already faced by A&E wards across the country, we believe that these proposals will further overstretch emergency care capacity.
4.3 Preventative care at the level of primary healthcare is cost-efficient and ensures the best healthcare outcomes in terms of public health and the individual wellbeing of patients.
5. Proposals to Extend Charging Principles Will Not Save Money
5.1 Refused asylum seekers and many irregular migrants will simply not have the funds to cover their healthcare costs. For individuals who cannot afford these costs, the psychological pressures of being hounded by collection agencies would be incredibly detrimental to physical and mental wellbeing. The costs incurred by the NHS in attempting to recover these funds will surely end up higher than any charges recovered from these patients.
5.2 If charging is expanded to cover primary care, it will require huge financial investment, both in terms of set up costs and in the administrative resources required to run the system. Furthermore, the only way to check eligibility for NHS services in a way which does not rely on racial profiling is to check everyone. Reviewing patients’ immigration status will be time consuming, costly and frustrating for patients and staff.
5.3 The Chairman of the Royal College of GPs also noted that the costs of the proposed charging system, with its related set-up, transaction and collection costs, “would far outweigh” what would ever be recouped in charges. (For further information about the Royal College of GPs response to the extension of charging principles, see this report.) This concern is echoed in the Department of Health’s qualitative research project undertaken with health professionals in 2013 (see page 14).
5.4 It should be stressed that both GPs and clinicians in hospitals have a duty to provide urgent or immediately necessary treatment, regardless of an individual’s ability to pay. If healthcare professionals are required to ration access to healthcare based on immigration status, this could become a violation of professional codes of conduct. In the words of the Royal College of General Practitioners, “GPs must not be a new border agency in policing access to the NHS.”
6. We’re Not Convinced by the Evidence…
6.1 33 doctors in London wrote to the Immigration Bill Committee stating that in their collective years of working in the NHS, they had not witnessed a single incident of health tourism. Even research conducted by the Department of Health found that only 4 people in a sample of 1000 across 15 different Trusts could be identified as ‘health tourists.’ Fundamentally, according to the Department of Health’s researchers, “the estimates for health tourism, as for any unlawful activity, are impossible to estimate with confidence.”
6.2 In 2007, in a report on the Treatment of Asylum Seekers in the UK, the Joint Committee on Human Rights, came to the following conclusion about charging refused asylum seekers for healthcare:
“no evidence has been provided to us to justify the charging policy, whether on the grounds of
cost-saving or of encouraging refused asylum seekers to leave the UK.”
6.3 The NHS is reliant on migrant workers! 26% of NHS doctors are foreign nationals, prompting the British Medical Association to observe that without the contribution of non-British staff, “many NHS services would struggle to provide effective care to their patients.” Arguably, migration has helped the NHS continue to provide world class care.