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Upfront NHS charges one year on – 6 reasons why they harm us all

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And what can we do to stop these harmful charges?

Ed Jones

When you’re expecting a baby the last thing you want to be thinking about is whether you can afford over £6,000 to go into hospital for the labour. For most people in England this isn’t yet a consideration but for the past year it has been the reality for many migrant women.

A year ago today, the government introduced upfront NHS charges for certain migrants as part of its ‘hostile environment’. Before that bills were sent after people received medical care. Primary care (i.e. GP visits), visits to accident and emergency, and treatment for some infectious diseases remains free for all. However, secondary care (such as being on a ward in the hospital or X-Rays), community care (including midwifery and abortion services), and care deemed ‘non-urgent’ is now liable for upfront costs for many migrants.

I’ve seen it for myself when I volunteered with Doctors of the World, supporting migrants to access healthcare in the UK. One patient we saw had a stroke, and was admitted to hospital unconscious. They were not charged for their time in A&E, however they were charged over £40,000 for their time in the Intensive Care Unit (secondary care). The Doctors of the World clinics in London see many cases where lifesaving care – including cancer chemotherapy, surgery and palliative care – is withheld unless paid for upfront because it is classified as ‘non-urgent.’

The Windrush scandal has shown how ‘hostile environment’ policies – which are also present in housing, banking, employment and other areas – can devastate people’s lives.

Evidence is mounting that turning medical professionals into border guards is a bad idea. Here’s why – and what we can do about it.

1) Lives are at risk
Volunteers at Doctors of the World have seen many people deterred from going to the doctor because they are worried they can’t afford the charges or that they will be reported to – and deported by – the Home Office. People’s health conditions often get worse as a result, as research by Doctors of the World has shown.

Women have not been accessing antenatal, perinatal and postnatal care because they are scared of mounting up debts or being reported to the authorities, a recent Maternity Action report found. This means unborn babies and mothers are more at risk of poor outcomes, including death, low birth weight and the transmission of various diseases. Doctors of the World’s research at their London drop-in clinic reached similar conclusions.

Under current regulations, if people incur healthcare debts over £500 they can be reported to the Home Office after only two months of non-payment. Maternity Action found that women – many of whom had just given birth – were being sent threatening NHS bills and some had been chased by debt collection agencies. They also spoke to women who had been wrongly charged for their care.

We are in the middle of the biggest refugee crisis since the Second World War, partly fuelled by British foreign policy and arms sales. Do we really want the government to respond by preventing access to medical treatment to those in need, including pregnant women?

2) It is a public health risk
NHS charges deter and delay vulnerable migrants from seeking the healthcare that they need, increasing harm to the individual and putting the health of the public at risk, as research conducted by post-graduate students at Kings College London at a Doctors of the World clinic has confirmed.

If people don’t go to the doctor when they need to it will increase the spread of infectious diseases, including drug resistant strains of tuberculosis (TB). Although treatment for many infectious diseases do not incur charges under the current system, many migrants do not know that this is the case. Research in the European Journal of Public Health looking at 100 recent migrants diagnosed with tuberculosis, found that at least 69% of them did not know that TB treatment was free prior to their diagnosis. Another recent study in the journal Thorax looking over 2,000 tuberculosis cases showed a significant association between the roll out of NHS charging and worsening delays in diagnosis amongst the non-UK born population.

3) It’s a false economy and will likely cost the NHS more money than it saves.
The Department of Health previously estimated that it was unclear whether the NHS charging system generated a net benefit or a net loss in an Internal Review of the Overseas Visitor Charging System. This is in large part due to the administrative cost of charging people and running an overseas charging team. Quantifying the cost of healthcare visits requires a vast amount of administration time, taking doctors and nurses away from providing care. It requires a huge investment in time providing training in costing, determining who is eligible or not, then ongoing time allowed to cost medical interventions. This needs to be supported by administration, managerial and accountancy staff to process bills and chase payments. Billing equipment is also needed as well as training, engineering and IT support to maintain the above.

When people don’t go to the doctor early on, many health conditions can also become much more difficult and costly to treat, especially if they worsen, become chronic and/or spread if infectious, resulting in more people turning up to A&E. For example, high blood pressure can be relatively cheap to treat and manage early on, but if left unchecked it places patients at risk of a number of conditions including cardiovascular disease. Untreated high blood pressure may end up in A&E with a heart attack and require much costlier interventions – such as heart bypass surgery – with all the associated costs of stays in hospital.

Health tourism is currently a very small percentage of NHS costs – the upper end of the government’s rough estimates are around 0.3%. The cost of what little ‘health tourism’ that exists, including treatment for British ‘expats’, would be covered thousands of times over if tax avoidance loopholes were closed. Everyone living in and visiting the UK also pays some tax – it is almost impossible to avoid taxes such as VAT. Bearing this in mind it just doesn’t make sense to suffer all these problems to attempt to recover a small portion of the NHS budget.

4) Upfront charges undermine the universality of the healthcare system and expand the infrastructure to further privatise the NHS.
Depending on how you measure it, around 8% of the NHS services have already been outsourced to private providers, although privatisation is much more extensive if you include the internal market, private finance initiatives, and withdrawal and restriction of services. What, or who, will be next? Introducing upfront charges for migrants has made it potentially much easier to do the same for other groups of patients and normalises the concept of upfront charging.

5) It sets a terrible international example
The system potentially will reduce access to healthcare for UK citizens when they travel abroad. Until recently, we had one of the most inclusive healthcare systems, so why change it? The US demonstrates how large private medical bills deter the poor, vulnerable and people of colour from accessing healthcare. This is a large part of why so many women die during childbirth in the US.

When Aneurin Bevan – a former miner and Trade Union activist – led the creation of the NHS as Health Minister after the Second World War, he intentionally ensured that the healthcare system was universal for all, including visitors to the UK. He wanted to set a positive example, in part to ensure British people are treated when abroad, but also as a positive example of what can be done internationally.

6) It is a racist policy.
This policy denies basic human rights to healthcare and asks healthcare workers and receptionists to determine whether someone can access healthcare – which is not the job they have trained for and distracts from what should be their priority: the care of the patient. Indeed, many NHS professionals are confused on how the new rules should be applied, with some incorrectly thinking that some patients are ineligible for life-saving medical care.

‘Hostile environment’ policies can also target people with names that don’t sound ‘British’, as well as people of colour. If people can’t prove their status they may fall foul of the system. On top of that, 17% of UK residents don’t have a passport at all, according to the 2011 census. This has implications for some of the UK’s most vulnerable citizens, including the homeless and those living in poverty.

What can we do?
There have been some significant wins for the growing campaign against the ‘hostile environment’ in healthcare. In May 2018 the government reversed arrangements to share patient details with the Home Office. The government has also significantly backtracked over the Windrush scandal. Change can happen – here are some ways you can help:

1) Today – 23rd October 2018 – there is a day of action focusing on supporting healthcare workers that are resisting ID checks and upfront charging in Barts Health NHS Trust in London – the Facebook event page has the timetable. There will be pickets at 3 Barts hospitals in the morning, a #PatientsNotPassports selfie twitter storm between 12 and 2pm aimed at Barts Trust, and a rally at the Royal London Hospital in the evening from 6PM. Join online or in person!

2) Sign the pledge to stop NHS charges.

3) Get involved with Docs Not Cops (Facebook, @DocsNotCops) or the Medact refugee solidarity group (Facebook, @Medact) who are both fighting to stop the targeting of migrants in healthcare. They are open to everyone, not just doctors and other medical professionals.

4) Volunteer with or donate to Doctors of the World to help ensure migrants access healthcare in the UK. You don’t have to be a medical professional to volunteer – you can do clinic support, case work or other tasks. GPs, nurses and medical students are also needed.

5) If you work in healthcare, do not ask to see ID, or turn a blind eye when you can. See who will co-operate with you in your workplace. Please bear in mind this will work better in some places than others. This is partly because patients could be identified to be charged at a later time than admission, or at a later admission, and will then still be eligible for the full cost of the care. See the Patients Not Passports toolkit which has a step-by-step advocacy guide to help healthcare workers find a way to exempt patients, gives detailed signposting advice, and also provides support to start campaigns.

6) If you are a member of the public, if you can, do not comply with requests to show forms of identity like passports and driving licenses when accessing NHS care. Support those targeted when you witness racial discrimination and report it to Docs Not Cops or Doctors of the World.

7) If you work in healthcare join a union like Doctors in Unite which vows to support NHS staff who refuse to act as ‘border guards’ and opposes the ‘hostile environment’ in healthcare. Alternatively get your current union to vow to provide such support as well as campaign on this.

Further reading
Understanding changes to NHS charging regulations for patients from overseas by Dr Lisa Murphy, Dr Joanna Dobbin, Dr Sarah Boutros in the British Journal of Hospital Medicine.

Patients Not Passports – A toolkit designed to support you in advocating for people facing charges for NHS care, and in taking action to end immigration checks and upfront charging in the NHS. By Docs Not Cops, Medact and Migrants Organise.

A GUIDE TO THE HOSTILE ENVIRONMENT: The border controls dividing our communities – and how we can bring them down by Liberty (editor).

Who has to pay for the NHS and when? By Jessica Potter in The Conversation.

Publications by Doctors of the World – includes policy briefings, evidence submissions and research reports.

The Hostile Environment: turning the UK into a nation of border cops by Corporate Watch.

What Price Safe Motherhood? Charging for NHS Maternity Care in England and its Impact on Migrant Women by Maternity Action.

Patients Not Passports – No borders in the NHS! by Jessica Potter in collaboration with Docs Not Cops.

Tuberculosis: looking beyond ‘migrant’ as a category to understand experience by Jessica L Potter & Adrienne Milner, Race Equality Foundation Briefing Paper.

Did migrants with tuberculosis in the UK know their condition was exempt from charges? by J Potter, V White, D Swinglehurst, C Griffiths in the European journal of Public Health.

Upfront charging of overseas visitors using the NHS by Lucinda Hiam and Martin McKee, in the BMJ.

The NHS and migrant patients with cancer by Sophie Williams, Erin Dexter, Jessica L Potter, in the Lancet.

Implications of upfront charging for NHS care: a threat to health and human rights by James Smith and Erin Dexter, in the Journal of Public Health.

Tougher charging regime for “overseas” patients by Sarah Steele et al., in the BMJ.

Roghieh Dehghan: A migrant GP on upfront NHS charges, in BMJ Opinion.

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