GP advocacy in supporting migrant access to NHS healthcare

Abstract

Recent policy reform within the NHS poses significant challenges to accessing healthcare for migrants. This follows the introduction of upfront charging in healthcare services for those not ordinarily resident in the UK. The eligibility for free NHS care is currently determined by an individual’s immigration status. This has denied treatment to many of those who lack the relevant financial means, particularly the migrant population. Migrants are recognised to have various complex health needs and to experience a number of difficulties in accessing healthcare, from language barriers to navigating through an unfamiliar healthcare system. There is also concern that migrants may be deterred from engaging with healthcare services after certain policies have mandated NHS trusts to share confidential patient information with the Home Office. Restrictive NHS policies are likely to exacerbate existing barriers for access to healthcare, which could have a devastating impact on migrant health. Similarly, this may inadvertently widen health inequalities and increase the disease burden in society. GPs hold a valuable role, in which they can advocate on behalf of their patients. Advocacy support can empower migrants in making informed decisions and help to protect their rights in accessing healthcare. This article provides a concise overview of the wider impact of restrictive policies within the NHS, and supports GPs in advocating on behalf of migrants to improve their access to healthcare.

Case study 1: Samantha.

Samantha is 68 years old and is part of the ‘Windrush’ generation who arrived in the UK from the West Indies in response to post-war labour shortages. Her right to live and work in the UK was mandated by ‘The British Nationality Act 1948’. This policy waived the requirement for documentation on entry to the UK and granted her the right to remain permanently. Samantha worked as a nurse in the NHS for the majority of her career.

Following retirement, Samantha started to experience mental health difficulties and was later diagnosed with Alzheimer’s disease at her annual GP review. Samantha’s GP referred her for specialist psychiatric care in the community to help manage her condition. However, Samantha was denied access to her local community mental health services, as she could not produce paperwork proving her right to reside in the UK. Samantha’s son, Marshall, moved in with her to provide care support for her mental health problems. In 2017, Samantha received a diagnosis of breast cancer and required in-patient chemotherapy treatment. However, as cancer treatment is not classed as ‘urgent’ or ‘immediately necessary’, Samantha was required to pay thousands of pounds upfront prior to treatment, beyond her financial means. Samantha was again denied medical care on the basis of her immigration status.

Samantha’s mental health and breast cancer have since deteriorated and remain poorly managed. Her son, Marshall, has subsequently experienced significant caregiver burden and stress. He is working with advocacy support groups to challenge these decisions regarding his mother’s care. Many of the ‘Windrush’ generation have experienced similar difficulties to Samantha in the refusal of healthcare, as well as becoming vulnerable to deportation by the Home Office.

Background

Asylum seekers, refugees, refused asylum seekers and undocumented migrants are identified as some of the most vulnerable groups living in the UK today. These populations often have diverse and complex health needs associated with their personal experiences before, during and after migration. These needs include, but are not limited to, maternity care, mental health and specialist support needs, poorly controlled chronic conditions and infectious diseases (British Medical Association, 2020). These health challenges are complicated by various socioeconomic factors and language barriers. However, following recent policy changes, NHS healthcare has become increasingly difficult to access for these minority groups, due to their immigration status. It is important for readers to familiarise themselves with the terms used to define immigration status, summarised in Table 1. These will be used throughout the course of this article.

Table 1.

Terms for immigration status.

Immigration status	Definition
Asylum seeker	A person who has left their country of origin and applied for asylum in the UK, but is waiting for a decision on their application
Refugee	A person whose asylum application has been accepted
Refused asylum seeker	A person whose asylum application has been unsuccessful
Undocumented migrant	A person who enters or stays in the UK, but is without the documentation required under immigration regulations

Upfront charging in the NHS

Following the legislation of a series of hostile environment policies by the Home Office, staying in the UK became progressively harder for refused asylum seekers and undocumented migrants. These policies extended widely into the public sector, particularly the NHS. In 2015, changes were made to the ‘National Health Service Regulations’ where access to healthcare services became more difficult for individuals not ordinarily resident in the UK. This included the introduction of an immigration health surcharge for those applying to stay in the UK for longer than 6 months (Medact, 2020). More recently, NHS trusts are now legally required to verify patient eligibility for free healthcare based on their immigration status. Patients who are considered ineligible incur upfront charges for secondary healthcare, at 150% of the NHS standard tariff rate (Department of Health & Social Care, 2017). These charges apply when the patient’s need for treatment is clinically judged as ‘non-urgent’. It is understood that this refers to routine and elective medical treatment, which could wait until the patient leaves the UK and returns to their country of original residence. The payment is required in full and in advance of the treatment. Healthcare charges for migrants in the NHS can range from £40 to £80 000, with the most common charge billed around £2600 (Doctors of the World, 2019a). The costs for individual procedures can vary, from £119 for an echocardiogram to £400 for renal dialysis, with adult critical care costing up to £1679 per day (NHS England and NHS Improvement, 2020).

The upfront charges apply to hospital-based care, as well as secondary community care services. This includes community mental health, termination of pregnancy services, district nursing and community midwifery. Maternity care is classed as ‘immediately necessary’ and thus must always be provided, but charges are incurred following the provision of care. These retrospective charges apply for all healthcare services that are provided to a patient where their clinical need is deemed urgent or immediately necessary.

There remain a number of NHS services that are exempt from upfront charges, such as GP and Accident & Emergency (A&E), as outlined in Box 1 (Public Health England (PHE), 2021).

Box 1.

NHS services exempt from upfront charges.

• GP and walk-in centres

• A&E and urgent care centres

• Notifiable infectious diseases (Schedule 1)

• Examples: COVID-19, Human Immunodeficiency Virus (HIV), Tuberculosis (TB), Middle East Respiratory Syndrome (MERS)

• Sexual health services

• Family planning services (excluding termination of pregnancy and infertility treatment)

• Palliative care services

• Treatment of physical/mental condition caused by: female genital mutilation, torture, domestic violence, sexual violence

• Telephone triage (111, 999)

Source: PHE (2021)

Upfront charging against migrants challenges the principles on which the NHS was founded, such as universality and being free at the point of delivery. This is because it denies treatment to those who need it, but lack the sufficient financial means to pay. Many patients with chronic and debilitating conditions are refused specialist NHS care unless their condition is deemed to be at a high risk of deterioration if left untreated before the return to their country of origin.

Patients exempt from upfront charges include refugees, asylum seekers and those with indefinite leave to remain, as highlighted in Box 2 (PHE, 2021). Whereas those deemed ineligible are primarily undocumented migrants and refused asylum seekers. However, it is important to note that immigration status remains subject to change, and many individuals may be incorrectly excluded by the eligibility criteria. This includes groups who are entitled to citizenship, but lack sufficient documentation, such as the ‘Windrush’ generation. Other groups include those whose indefinite leave to remain has lapsed, children of undocumented migrants and those appealing against failed asylum.

Box 2.

Patient groups exempt from upfront NHS charges.

• Individuals ordinarily resident in the UK

• Refugees and their dependents

• Asylum seekers and their dependents (including appeals)

• Individuals receiving compulsory psychiatric treatment under a court order, detained in NHS hospital or deprived of liberty

• Children looked after by a local authority

• Prisoners and immigration detainees

• Victims of human trafficking/modern slavery

• Individuals who hold a European Health Insurance Card or have paid the Immigration Health Surcharge

• Refused asylum seekers under specific criteria

Source: PHE (2021)

Identification checks

Although not a legal requirement, patients may be asked to produce a form of photo ID and proof of address when registering with a GP (PHE, 2021). These identification checks are likely to prove challenging, as 16.5% of UK residents do not hold a passport (Office for National Statistics, 2013). There are also a significant number of vulnerable groups for whom the provision of a home address would be difficult. These include homeless people, asylum seekers, undocumented migrants and those living with mental health problems. Even though GP registration cannot be legally denied on the lack of identity documentation, some practices have wrongly refused patients on these grounds (Doctors of the World, 2018b). This could lead to the gatekeeping of healthcare, which would have a detrimental impact on migrant health and deter future engagement with primary care services.

For access to secondary care services, a patient’s immigration status is required to establish their eligibility for free NHS care. Identification checks for hospital care were previously piloted indiscriminately to determine eligibility for care, but proved inefficient and impractical. In 2016, the Department of Health & Social Care launched a trial of identification checks across 18 NHS trusts. However, of the 8900 patients who required identity checks in the pilot, only 50 were deemed ineligible for free NHS care (Lydall, 2019). These trials paved the way for the more recent policy of verifying proof of eligibility for NHS care, which is laden with issues including racial bias (Papageorgiou et al., 2020).

The process of identifying potentially chargeable patients for secondary care varies by NHS trust. This generally occurs once a patient has been flagged for lacking a GP or NHS number, which then prompts an invoice or letter requesting proof of eligibility through documentation. This may take place prior to an appointment, during a hospital stay or after care has been received. However, where a patient’s immigration status is not available, NHS trusts may seek information from the UK Home Office’s ‘Status Verification and Enquiries Checking’ service (Department of Health and Social Care, 2019). In order for the Home Office to confirm a patient’s immigration status, the NHS must provide them with certain patient details, including name, date of birth and home address if known.

Data sharing

In 2017, a Memorandum of Understanding (MoU) was established between the Home Office and NHS Digital, the body responsible for holding NHS patient data. This MoU represented a data-sharing agreement, which allowed for the mass sharing of personal patient information to the Home Office for the purpose of immigration enforcement. Patient details, including home addresses, were used to detain and deport refused asylum seekers and undocumented migrants (Home Office, Department of Health and NHS Digital, 2019). A lack of transparency surrounding this policy resulted in thousands of patients having their personal data shared without consent.

Healthcare professionals appealed the MoU agreement after raising concerns that it compromised patient confidentiality and alienated vulnerable patients (Iacobucci, 2018). The MoU agreement was subsequently withdrawn in 2018, however, re-negotiations for a revised MoU have since begun (NHS Digital, 2018). Home Office requests for patient data are now limited to individuals considered a risk to public safety following serious criminal offences. However, NHS trusts remain mandated to document a patient’s chargeable status for care on their health record. They are also required to report patients with outstanding NHS debts to the Home Office. This includes a debt of £500 or more for a period of 2 months or longer, or £1000 or more for a period of 3 months or longer. This debt may then be used by the Home Office to refuse leave to remain in the UK and can affect future immigration applications (PHE, 2021). In some circumstances, this may result in detention and deportation.

Impact on patients

Financially, many vulnerable migrants do not have the sufficient means to pay the upfront charges for the healthcare they require. An inaccurate clinical assessment and wrongful application of overseas charging regulations can result in patients being inappropriately charged for healthcare services, particularly those who are exempt. Similarly, those requiring urgent care may be denied treatment if their clinical need is not sufficiently relayed (Fox and Hiam, 2018). This is likely to worsen disease outcomes of many individuals with serious conditions. The deterrent and displacement effects of restricted healthcare access can also worsen patients’ psychological and social wellbeing (Doctors of the World, 2019a).

The breaches of patient confidentiality following the MoU agreement have left many vulnerable individuals fearful of facing immigration enforcement as a consequence of accessing healthcare. Subsequently, there have instances in which patients have withheld important details during consultations or provided false identification to clinicians, which may harm patient and public safety (Papageorgiou et al., 2020).

Impact on society

These policies may deter patients from accessing healthcare, which is likely to increase the disability and disease burden in the UK. The charging regulations in the NHS can discourage patients from engaging with the cost-efficient means of preventative care and planned consultations. This can lead to patients becoming acutely unwell and increase the expensive use of A&E services. The cost of delivering A&E services is reported to be around £4 billion per annum (Royal College of Emergency Medicine, 2017). The policies limit the access to preventative care and planned consultations for migrants, which is safer and more economical than using acute services. Timely intervention in primary care could help migrants save up to 93% in medical and non-medical costs associated with hospitalisation (Center for Health and Migration, 2016).

The cost-efficiency of the upfront charging policy in the NHS remains relatively unknown. Moreover, restricted healthcare access among the migrant group is likely to widen existing health inequalities in the UK, which are estimated to cost the NHS £5 billion per annum (Institute of Health Equity, 2010).

Case study 2: Maya.

Maya, 32 years in age, is an asylum seeker. After fleeing political violence in her home country Iraq, she sought asylum in the UK. Maya experienced significant traumatic experiences in Iraq, including domestic abuse and rape. Her claim for asylum is undergoing its first appeal after initial rejection.

On arrival to the UK, Maya was homeless and relied on migrant shelters for temporary accommodation. Maya was initially hesitant to access healthcare after her close friend, Rana, was deported as per the data-sharing agreement between the NHS and Home Office. Maya eventually attempted to register at a local GP practice after finding out that she was pregnant. However, she was wrongly refused registration for not having a proof of address. Maya remained unaware of her right to maternity care in the NHS. Without adequate access to antenatal care, Maya presented with vaginal bleeding during the early stages of pregnancy and subsequently suffered a miscarriage.

One year later, Maya successfully registered with a GP practice following the help of outreach support groups. The clinic highlighted good practice by providing inclusive registration policies and adequate translation services. During consultations, the GP reassured Maya that she is in a safe space and that her information is protected. The GP advocated on Maya’s behalf, ensuring her right to adequate maternity care during her second pregnancy. Maya successfully gave birth to her first child soon after. However, upon receiving maternity care she incurred a debt worth thousands of pounds having been incorrectly identified as a refused asylum seeker. The GP referred Maya to the advocacy support group ‘Maternity Action’ for further support in disputing this healthcare charge.

The GP as a patient advocate

There is expected to be greater pressure on GP services with healthcare policy reform extending into community secondary care services. With limitations in accessing specialist care, there is likely to be an increased disease burden in the community. However, there are also a number of perceived barriers that deter migrants from accessing primary care. These most commonly include a lack of understanding of the structure of the NHS and language barriers (Kang et al., 2019).

The GP curriculum highlights the importance of the GP’s role as a patient advocate (Royal College of General Practitioners, 2019a, 2019b). The GP is often the first point of contact and the channel through which patients are able to access secondary care. GPs can advocate on behalf of their patients to facilitate their access to the healthcare they need. Advocacy support empowers patients in making informed decisions related to their care and allows for fairer access to available services. It also helps to protect the rights of patients in view of policy changes in healthcare (Schwartz, 2002). Figure 1 provides a helpful framework for practitioners when advocating for their patients.

Figure 1.

Steps for GPs to facilitate healthcare access.

Advocacy support can benefit migrants facing healthcare charges. It is important for GPs to carry out thorough clinical assessment, as access to specialist care depends on patient need for treatment. Doctors of the World have published a useful guide to support clinicians in recognising ‘urgent’ and ‘immediately necessary’ care for chargeable patients (Doctors of the World, 2018a). This includes accounting for factors such as pain, disability, prognosis and level of risk. Furthermore, by staying up-to-date with healthcare policies, GPs can educate migrants on the healthcare services available to them and exemption criteria if necessary. Public Health England outlines all the up-to-date guidance regarding the NHS entitlements available to migrants (PHE, 2021).

Following the data-sharing agreement, it remains highly important for GPs to protect patient confidentiality during their practice. Patients should be reassured that their personal information is safe, and that it will only be shared with consent. Similarly, transparency should be provided with patients where information must be shared out of legal duty, as per the guidance from the General Medical Council. Within their practices, GPs should support their patients in accessing primary care. Doctors of the World have developed a ‘Safe Surgeries’ toolkit to help widen access to primary care (Doctors of the World, 2018b). This encourages the use of adequate interpretation services, advocating for more inclusive registration policies, and reassuring patients of their right to care without the fear of immigration enforcement. As part of the ‘Safe Surgeries’ Quality Improvement Project, GP trainees have the opportunity to implement inclusion health measures within their practice (Doctors of the World, 2019b).

GPs can provide further help to migrants by signposting them to supportive advocacy organisations and charities as outlined in Table 2. These groups offer specialist, up-to-date advice to migrants impacted by healthcare policies in the NHS. They can help to examine and challenge healthcare charges and refusals of care, as well as set up payment plans for accessing care. Referral and follow-up with the patients and organisations are important to ensure that any charges or refusal of care have been examined and challenged, with the patient’s consent, and any payment plan options discussed and set up with secondary care where appropriate. This is also important for patients’ future immigration applications to the Home Office, which can be negatively affected by any outstanding, unpaid NHS bills.

Table 2.

Useful advocacy support groups for migrants.

Organisation	Role
Doctors of the World	Provide useful resources for GPs to widen migrant access to healthcare, such as the ‘Safe Surgeries’ initiative.
Maternity Action	Promote and protect the maternity rights of patients
Docs not Cops	Collaborated together to establish #PatientsNotPassports, an advocacy toolkit for healthcare and community workers to support patients facing charges for NHS care. They are also involved in campaigning to reform restrictive healthcare policies.
Migrants Organise
Medact

GPs remain in a strong position to advocate on behalf of their patients, widen access to healthcare and minimise health inequalities. An understanding of the impact of healthcare policies on migrants and the role of advocacy support can help to improve health outcomes in primary care.

KEY POINTS

Recent policy reform has introduced upfront charging, data sharing and identification checks in the NHS

GP and A&E services remain free to access, however, specialist care is chargeable for certain migrant groups

Failure to pay upfront results in a refusal for treatment unless a patient’s need for treatment is clinically deemed as being urgent or immediately necessary

The policies have raised concerns over widening health inequalities and breaching patient confidentiality

Migrant groups have complex health needs and are deterred from accessing healthcare they require

GPs can help to support and empower migrants by advocating on their behalf and protecting their rights to healthcare

Footnotes

ORCID iD

Anish Verma

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