BMJ 2016;352:i685 doi: 10.1136/bmj.i685 (Published 9 February 2016)
Page 1 of 2
Editorials
EDITORIALS Extending migrant charging into emergency services New proposals make the NHS the most restrictive healthcare system in Europe for undocumented migrants 1
1
Sally Hargreaves senior research fellow , Laura Nellums research associate , Jon S Friedland 1 1 2 professor , Jacob Goldberg research nurse , Philip Murwill clinic manager , Lucy Jones programme 2 manager International Health Unit, Section of Infectious Diseases and Immunity, Department of Medicine, Imperial College London, London W12 0NN, UK; Doctors of the World UK, London E14 5AA, UK
1 2
The Department of Health is proposing to extend charging for migrants into some NHS primary care services and emergency departments.1 Although the government asserts that the NHS is “overly generous to those who have only a temporary relationship with the UK,”2 these proposals will make the NHS a highly restrictive healthcare system for migrants to access care and treatment.3 4 Of particular concern is the effect on the thousands of undocumented migrants living without legal status in the UK, who are often marginalised, vulnerable to abuse and exploitation, and have poor health outcomes.5-7
This is the third consultation on migrant charging since 2004. The 2013 consultation,2 which launched the NHS visitor and migrant cost recovery programme, was framed in the context of restricting services and making the UK a “hostile environment” for undocumented migrants. It was debated alongside the 2014 Immigration Bill, described by the Migrants’ Rights Network as “the most draconian challenge to the rights of migrants, and the communities they live in, for a generation.” Phases 1-3 of the 2014-16 implementation plan have so far introduced incentives for services to identify chargeable patients, piloted the recovery of costs for European economic area (EEA) nationals, and introduced a 150% tariff in secondary care for non-EEA nationals and the immigration health surcharge. In addition, information sharing is now taking place between the NHS and Home Office systems to improve the identification of chargeable migrants and for immigration enforcement.
These ongoing strategies are projected to recoup £500m (€660; $720). However, the projected savings from changes in the current consultation are only £60.7m over five years, with just £5.7m of that coming from charging in emergency departments.8 The proposed extensions to charges will not only recoup much less money but will also be more difficult and potentially dangerous to implement. Furthermore, the estimated savings have been heavily criticised in terms of cost effectiveness, and no cost has been attributed to staff involvement and implementing service changes.2-7 Government commissioned
research has highlighted the challenges to implementation, including the negative effect on access to care and the efficiency of trusts.9
Though it may be advantageous to recoup costs from visitors coming from countries with which the UK has reciprocal health agreements—which has accounted for most recovered costs to date—targeting undocumented migrants raises concerns because many of them will be unable to pay. The more restrictive policies introduced since 2004, which have undoubtedly affected both entitled and non-entitled migrants, discriminate against vulnerable groups (including children and pregnant women, who are not exempt from charging), increase health inequalities, and—importantly—discourage people from seeking timely care and preventive care such as screening and vaccination.6-10 This has implications for both individual and public health, leading to increased transmission of infectious diseases such as tuberculosis and HIV infection that are more prevalent in migrant populations, even though treatment will remain free of charge.6-11 These policies run contrary to other national strategies, including engaging high risk migrant groups in screening for latent tuberculosis.12 What is alarming in this latest consultation is the commitment to expand charging into emergency services. For many undocumented migrants, the emergency department represents their only source of government funded primary and secondary healthcare, alongside limited provision from non-governmental organisations such as Doctors of the World; for some vulnerable migrants,including victims of trafficking, the emergency department provides a safe and anonymous place to present.13 Migrants in the UK already face known barriers to registering with primary care services,10-14 leaving them few options. Currently, most other European countries allow undocumented migrants to access free care through emergency departments.4 In Spain and Sweden, where more restrictive access arrangements were introduced, the governments subsequently reversed the decision because they were unworkable and
Correspondence to: S Hargreaves [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2016;352:i685 doi: 10.1136/bmj.i685 (Published 9 February 2016)
Page 2 of 2
EDITORIALS
excluding migrants from healthcare and screening created numerous health risks.
The latest consultation suggests, however, that despite multiple reservations and unanswered questions around expansion of charging systems in recent years, the horse has already bolted. As a next step, we would like to see a formal evaluation of phases 1-3 to assess the effect on patients and NHS services. Robust research must be done into the cost effectiveness and health implications of expanding charging systems further, before implementation. The government should refrain from making policy decisions to address the NHS’ financial problems based on populist reactions, through targeting undocumented migrants for charging, rather than on robust evidence. One million migrants entered Europe in 2015, and a growing number will continue to travel to the UK with few options to access a basic acceptable level of healthcare under these current proposals. The time has come to question the direction that the UK, and Europe, wants to go on migrant health, and to better define how to fund and deliver effective healthcare to migrants. This must be an evidence based, coordinated, and compassionate response. Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests. Provenance and peer review: Not commissioned; externally peer reviewed.
For personal use only: See rights and reprints http://www.bmj.com/permissions
1 2 3 4 5
6 7 8 9 10 11 12 13 14
Department of Health. Making a fair contribution: a consultation on the extension of charging overseas visitors and migrants using the NHS in England. Department of Health, 2015. Department of Health. Sustaining services, ensuring fairness: government response to the consultation on migrant access and financial contribution to NHS provision in England. Department of Health, 2013. Aleksic D. Provision of maternity servcies for undocumented migrants in the United Kingdom and six European Countries. Maternity Action, 2013. Médecins du Monde. Legal report on access to healthcare in 12 countries. 2015. https:/ /mdmeuroblog.files.wordpress.com/2014/05/mdm-legal-report-on-access-to-healthcarein-12-countries-3rd-june-20151.pdf. Prederi. Quantitative assessment of visitor and migrant use of the NHS in England: exploring the data. 2013. www.gov.uk/government/uploads/system/uploads/attachment_ data/file/251909/Quantitative_Assessment_of_Visitor_and_Migrant_Use_of_the_NHS_ in_England_-_Exploring_the_Data_-_FULL_REPORT.pdf. Deblonde J, Sasse A, Del Amo J, et al. Restricted access to antiretroviral treatment for undocumented migrants: a bottle neck to control the HIV epidemic in the EU/EEA. BMC Public Health 2015;15:1228. doi:10.1186/s12889-015-2571-y. 26654427. Britz JB, McKee M. Charging migrants for health care could compromise public health and increase costs for the NHS. J Public Health (Oxf) 2015;pii:fdv043; [Epub ahead of print]. doi:10.1093/pubmed/fdv043. 25904814. Department of Health. Visitor and migrant cost recovery—extending charging. impact assessment. 2015. www.gov.uk/government/uploads/system/uploads/attachment_data/ file/482648/Impact_Assessment.pdf. Creative Research. Qualitative assessment of visitor and migrant use of the NHS in England: observations from the front line—summary. Creative Research, 2013. Hargreaves S, Friedland JS. Impact on and use of health services by migrants in Europe. In: Thomas F, Gideon J, eds. Migration, health and inequality . Zed Books, 2013:27-43. Health Protection Agency. Migrant health: infectious diseases in non-UK born populations in the United Kingdom.- An update to the baseline report – 2011. Health Protection Agency, 2011. Public Health England. Latent TB testing and treatment for migrants: a practical guide for commissioners and practitioners. Public Health England, 2015. Department of Health. Supporting Victims of modern day slavery through healthcare services. Department of Health, 2015. Stagg HR, Jones J, Bickler G, Abubakar I. Poor uptake of primary healthcare registration among recent entrants to the UK: a retrospective cohort study. BMJ Open 2012;2:e001453. doi:10.1136/bmjopen-2012-001453. 22869094.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 2
Editorials
EDITORIALS Extending migrant charging into emergency services New proposals make the NHS the most restrictive healthcare system in Europe for undocumented migrants 1
1
Sally Hargreaves senior research fellow , Laura Nellums research associate , Jon S Friedland 1 1 2 professor , Jacob Goldberg research nurse , Philip Murwill clinic manager , Lucy Jones programme 2 manager International Health Unit, Section of Infectious Diseases and Immunity, Department of Medicine, Imperial College London, London W12 0NN, UK; Doctors of the World UK, London E14 5AA, UK
1 2
The Department of Health is proposing to extend charging for migrants into some NHS primary care services and emergency departments.1 Although the government asserts that the NHS is “overly generous to those who have only a temporary relationship with the UK,”2 these proposals will make the NHS a highly restrictive healthcare system for migrants to access care and treatment.3 4 Of particular concern is the effect on the thousands of undocumented migrants living without legal status in the UK, who are often marginalised, vulnerable to abuse and exploitation, and have poor health outcomes.5-7
This is the third consultation on migrant charging since 2004. The 2013 consultation,2 which launched the NHS visitor and migrant cost recovery programme, was framed in the context of restricting services and making the UK a “hostile environment” for undocumented migrants. It was debated alongside the 2014 Immigration Bill, described by the Migrants’ Rights Network as “the most draconian challenge to the rights of migrants, and the communities they live in, for a generation.” Phases 1-3 of the 2014-16 implementation plan have so far introduced incentives for services to identify chargeable patients, piloted the recovery of costs for European economic area (EEA) nationals, and introduced a 150% tariff in secondary care for non-EEA nationals and the immigration health surcharge. In addition, information sharing is now taking place between the NHS and Home Office systems to improve the identification of chargeable migrants and for immigration enforcement.
These ongoing strategies are projected to recoup £500m (€660; $720). However, the projected savings from changes in the current consultation are only £60.7m over five years, with just £5.7m of that coming from charging in emergency departments.8 The proposed extensions to charges will not only recoup much less money but will also be more difficult and potentially dangerous to implement. Furthermore, the estimated savings have been heavily criticised in terms of cost effectiveness, and no cost has been attributed to staff involvement and implementing service changes.2-7 Government commissioned
research has highlighted the challenges to implementation, including the negative effect on access to care and the efficiency of trusts.9
Though it may be advantageous to recoup costs from visitors coming from countries with which the UK has reciprocal health agreements—which has accounted for most recovered costs to date—targeting undocumented migrants raises concerns because many of them will be unable to pay. The more restrictive policies introduced since 2004, which have undoubtedly affected both entitled and non-entitled migrants, discriminate against vulnerable groups (including children and pregnant women, who are not exempt from charging), increase health inequalities, and—importantly—discourage people from seeking timely care and preventive care such as screening and vaccination.6-10 This has implications for both individual and public health, leading to increased transmission of infectious diseases such as tuberculosis and HIV infection that are more prevalent in migrant populations, even though treatment will remain free of charge.6-11 These policies run contrary to other national strategies, including engaging high risk migrant groups in screening for latent tuberculosis.12 What is alarming in this latest consultation is the commitment to expand charging into emergency services. For many undocumented migrants, the emergency department represents their only source of government funded primary and secondary healthcare, alongside limited provision from non-governmental organisations such as Doctors of the World; for some vulnerable migrants,including victims of trafficking, the emergency department provides a safe and anonymous place to present.13 Migrants in the UK already face known barriers to registering with primary care services,10-14 leaving them few options. Currently, most other European countries allow undocumented migrants to access free care through emergency departments.4 In Spain and Sweden, where more restrictive access arrangements were introduced, the governments subsequently reversed the decision because they were unworkable and
Correspondence to: S Hargreaves [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2016;352:i685 doi: 10.1136/bmj.i685 (Published 9 February 2016)
Page 2 of 2
EDITORIALS
excluding migrants from healthcare and screening created numerous health risks.
The latest consultation suggests, however, that despite multiple reservations and unanswered questions around expansion of charging systems in recent years, the horse has already bolted. As a next step, we would like to see a formal evaluation of phases 1-3 to assess the effect on patients and NHS services. Robust research must be done into the cost effectiveness and health implications of expanding charging systems further, before implementation. The government should refrain from making policy decisions to address the NHS’ financial problems based on populist reactions, through targeting undocumented migrants for charging, rather than on robust evidence. One million migrants entered Europe in 2015, and a growing number will continue to travel to the UK with few options to access a basic acceptable level of healthcare under these current proposals. The time has come to question the direction that the UK, and Europe, wants to go on migrant health, and to better define how to fund and deliver effective healthcare to migrants. This must be an evidence based, coordinated, and compassionate response. Competing interests: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests. Provenance and peer review: Not commissioned; externally peer reviewed.
For personal use only: See rights and reprints http://www.bmj.com/permissions
1 2 3 4 5
6 7 8 9 10 11 12 13 14
Department of Health. Making a fair contribution: a consultation on the extension of charging overseas visitors and migrants using the NHS in England. Department of Health, 2015. Department of Health. Sustaining services, ensuring fairness: government response to the consultation on migrant access and financial contribution to NHS provision in England. Department of Health, 2013. Aleksic D. Provision of maternity servcies for undocumented migrants in the United Kingdom and six European Countries. Maternity Action, 2013. Médecins du Monde. Legal report on access to healthcare in 12 countries. 2015. https:/ /mdmeuroblog.files.wordpress.com/2014/05/mdm-legal-report-on-access-to-healthcarein-12-countries-3rd-june-20151.pdf. Prederi. Quantitative assessment of visitor and migrant use of the NHS in England: exploring the data. 2013. www.gov.uk/government/uploads/system/uploads/attachment_ data/file/251909/Quantitative_Assessment_of_Visitor_and_Migrant_Use_of_the_NHS_ in_England_-_Exploring_the_Data_-_FULL_REPORT.pdf. Deblonde J, Sasse A, Del Amo J, et al. Restricted access to antiretroviral treatment for undocumented migrants: a bottle neck to control the HIV epidemic in the EU/EEA. BMC Public Health 2015;15:1228. doi:10.1186/s12889-015-2571-y. 26654427. Britz JB, McKee M. Charging migrants for health care could compromise public health and increase costs for the NHS. J Public Health (Oxf) 2015;pii:fdv043; [Epub ahead of print]. doi:10.1093/pubmed/fdv043. 25904814. Department of Health. Visitor and migrant cost recovery—extending charging. impact assessment. 2015. www.gov.uk/government/uploads/system/uploads/attachment_data/ file/482648/Impact_Assessment.pdf. Creative Research. Qualitative assessment of visitor and migrant use of the NHS in England: observations from the front line—summary. Creative Research, 2013. Hargreaves S, Friedland JS. Impact on and use of health services by migrants in Europe. In: Thomas F, Gideon J, eds. Migration, health and inequality . Zed Books, 2013:27-43. Health Protection Agency. Migrant health: infectious diseases in non-UK born populations in the United Kingdom.- An update to the baseline report – 2011. Health Protection Agency, 2011. Public Health England. Latent TB testing and treatment for migrants: a practical guide for commissioners and practitioners. Public Health England, 2015. Department of Health. Supporting Victims of modern day slavery through healthcare services. Department of Health, 2015. Stagg HR, Jones J, Bickler G, Abubakar I. Poor uptake of primary healthcare registration among recent entrants to the UK: a retrospective cohort study. BMJ Open 2012;2:e001453. doi:10.1136/bmjopen-2012-001453. 22869094.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions
Subscribe: http://www.bmj.com/subscribe
