Defend Primary Healthcare an introduction to the campaign

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Defend Primary Healthcarean introduction to the
campaign
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Defend Primary Healthcare

• Defining basic terms and destitution
• Healthcare for all? Governing rules and
  misconceptions
• Support network and what are the implications of
  destitution? (case study)
• Myths regarding healthcare
• Review of key documents
• What can we do?!

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Defining the basics

• Asylum seeker
• Refugee
• Failed Asylum seeker
• Undocumented migrant
• Economic migrant

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Defining the basics

• ASYLUM SEEKER
• Someone who is fleeing persecution in their
  homeland, has
• arrived in another country, made themselves known
  to the
• authorities and exercised the legal right to
  apply for asylum
• REFUGEE
• Someone whose asylum application has been
  successful. They have shown a well-founded fear
  of persecution because of their race, religion,
  nationality, membership in a particular social
  group or political opinion and that they are
  unable or unwilling to seek protection from the
  originating country, or to return there, for fear
  of persecution.
• .

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Defining the basics

• FAILED ASYLUM SEEKER
• Someone whose asylum application has been turned
  down and is awaiting return to their country. If
  it is not safe for refused asylum seekers to
  return, they may have to stay for the time being
  and become destitute (eligible for section IV
  support).
• UNDOCUMENTED MIGRANTS
• A mixed bag of trafficked people, visa
  overstayers, exploited labourers, and so on.
• ECONOMIC MIGRANT
• Someone who has moved to another country to
  work

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Destitution in the UK
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Destitution

• Destitution is the state of extreme poverty and
  not having the means to provide for oneself
• No clear figure. National audit office
  estimate155,000 and 283,500 people were destitute
  in July 2005. Some quote 400,000......
• Most common countries that destitute asylum
  seekers and refugees originate from
• DRC, Zimbabwe, Somalia, Iraq, Sudan, Eritrea,
  Iran, Cameroon, Uganda.

78 are between the age of 21-40. Many can
live in destitution anywhere between 1-2
years....however there are some living like this
for LONGER!!!!!
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Who are destitute?

• Refused asylum seekers (except those on a
  section)
• The interval between failing an asylum case and
  lodging an appeal
• Refugees ( newly granted status)
• Newly arrived asylum seekers
• An unaccompanied minor who has now turned 18

WHY DONT THEY GO HOME?! A) Many fear torture
and death on returning B) Home office recognise
that the return route is unsafe! In 2006, 25 in
repatriations c) Many are in too fragile a state
to make an informed decision regarding their
return
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What are the implications of destitution?

• Sleeping it rough
• Dependent on friends and family Couch surfing
• Removal of free healthcare rights (see
  exceptions)
• Removal of financial support ( exceptions)
• ? Primary care ( currently at the discretion of
  the GP)
• Huge reliance on faith projects and community
  organisations (5 and bag of food)
• Increased mental health problems, suicidal
  thoughts
• Exacerbation of medical problems
• Section 4
• Placed in detention centres

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2004 NHS (Charges to Overseas Visitors)
(Amendment) Act

• The first blow
• Secondary (hospital) care
• Not a change in law, but a statutory
• instrument (National Health Services Act,
  1977, authorises the secretary of state to
  impose them)?
• Predicated upon idea of 'health tourism'

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2004 NHS (Charges to Overseas Visitors)
(Amendment) Act

• Affected groups are...
• - failed asylum seekers awaiting deportation
• - failed asylum seekers receiving Section IV
  support
• - undocumented migrants
• Coupled with guidance to trusts encouraging the
  energetic pursuit of debt including
  consideration of using a debt collection
  agency where larger amounts are involved

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Important Exemptions

• Accident and Emergency and associated
  'walk-in' services
• GUM clinics and family planning
• Exempted infectious diseases (eg TB,
• measles, salmonella)?
• HIV testing BUT not ARVs or PMTCT
• Compulsory treatment for mental illness
• Treatments started whilst an asylum claim is
  still 'live' (the 'easement clause')?

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Immediately Necessary Treatment

• "Immediately necessary treatment to save life or
  prevent a condition from becoming
  life-threatening should always be given to failed
  asylum seekers without delay, irrespective of
  their eligibility for free treatment or ability
  to pay. However if they are found to be
  chargeable, the charge will still apply, and
  recovery should be pursued as far as the trust
  considers reasonable."
• INCLUDES OBSTETRIC CARE!

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Process

• ALL PEOPLE SHOULD BE ASKED...
• Where have you lived for the last 12 months?
• Can you show that you have the right to live
  here?
• IF 'NOT UK' OR 'NO' SHOULD BE REFERED FOR
  INTERVIEW WITH OVERSEAS PAYMENT OFFICER

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The Gap between Policy and Reality

• "We have heard of people being denied care who
  were entitled to it. How rigorously you are
  questioned about entitlement to treatment will
  depend on your name, accent and the
• colour of your skin"
• Yusef Azad, National AIDS Trust

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The Gap between Policy and Reality

• "E, a young woman from China, was turned away
  several times by her local NHS trust, who told
  her that unless she could pay them several
  thousand pounds upfront, they would not support
  her through the birth of her baby. She gave birth
  at home, with no medical care, and then both she
  and her baby had to be admitted to hospital with
  serious health problems relating to the traumatic
  birth. Once discharged, the hospital continued to
  send E bills, which frightened her so much she
  fled her home. The whereabouts of her and her
  child are not known."
• Refugee Council

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The Gap between Policy and Reality

• "A client has been receiving HIV treatment in
  London and was relocating to Bristol however, he
  was told that he would be refused treatment
  unless he paid. He was currently on combination
  therapy and needed it to continue in good health.
  He was distressed and afraid he would die without
  treatment. The client disappeared
• outcome not known."
• Terrence Higgins Trust

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And Primary Care?

• Confusing
• GPs have considerable discretion about
  whether they register people
• They can register people as temporary
  visitors, on a permanent basis if staying more
  than 3 months, or treat them as private
  patients
• New GP contract disincentives registering
  patients with more complex needs

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And Primary Care?

• If an asylum seeker loses their claim to asylum
  and all appeal processes have been exhausted (a
  failed asylum seeker), they become ineligible for
  routine NHS primary care treatment from the date
  their asylum claim failed. A practice will
  therefore charge the individual concerned as a
  private patient (with the patients consent) for
  any treatment which it provides, unless the
  treatment is emergency or immediately necessary.
  Similarly a NHS Walk in centre will operate NHS
  charges.
• Annex A, 2004 Primary Care Consultation Document

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And Primary Care?

• Guidance challenged in 2005
• In March 2006, the department clarified the
  position stating that GPs should not register
  failed asylum seekers but have the
• discretion to do so
• BMA guidance states that GPs have the right to
  register failed asylum seekers.

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Types of primary care facilities for refugees and
asylum seekers

• Mainstream care services
• Dedicated practices
• Supplementary provision in existing practices

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Needs of refugees and asylum seekers

• Physical Health
• - Communicable diseases
• - Non-communicable diseases
• Mental Health
• Sexual and reproductive health
• Nutrition
• Communication
• Counselling and social needs
• Services for torture victims

The registration of failed asylum seekers is at
the discretion of GPs.
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Remember access to services is not just about the
law...
Lack of awareness of available facilities. Unsure
what going to the doctors involves
Staff shortage within a health team e.g. Mental
health teams.
Communication barriers
GP quota
Cultural/ ethnic barriers
Factors influencing access to healthcare
Lack of a fixed postcode/ asylum status and
pre-occupations
Continuous dispersal of asylum seekers
Social isolation
Lack of training and awareness amongst health
staff. Confusion amongst health professionals
over the entitlements of refugees/asylum seekers
Financial hardship
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Organisations involved in the healthcare of
asylum seekers and refugees
Voluntary organisations
Education Services
Refugee communities
Religious organisations
Dentists
Organisations
Housing services
Health professionals
Social services
Employment
National Asylum Support Service (NASS)
Legal organisations
Services for survivors of torture and rape
Mental health services
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Myths
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Myth one

• Asylum seekers are draining millions from the
  NHS?
• There are thousands of medically trained
  asylum seekers and refugees who could contribute
  to the NHS and ease its acute staffing crisis but
  this potentially valuable resource to the NHS is
  being wasted because of work or regulatory
  restrictions.
• According to the Greater London Authority, in
  London, 23 of doctors and 47 of nurses working
  in the NHS were born outside the UK.
• BMA estimates NHS is currently short of
  20,000 doctors and consultants and there are
  roughly 3,000 refugee doctors living in the UK
  who are unable to practise. It takes about 10
  years and 250,000 to train a doctor from
  scratch, but only 1 year and 15,000 to refresh
  the skills of refugee doctors.

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Myth two

• The cost of HIV treatment for asylum seekers is
  depriving British people of essential medical
  services
• The total number of people living with HIV in the
  UK is 50,000. This accounts for just 0.28 of the
  total number of people living with a chronic
  disease in the UK (17.5 million) ? very small!!!
• The cost of treating and caring for people with
  HIV is 440m, or 0.9 per cent of the total NHS
  treatment and care bill - less than we spend on
  treating diabetes or kidney disease.

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Myth three

• Compulsory health screening of new asylum
  applicants would stop the rise of HIV and TB in
  Britain
• Medical experts believe compulsory screening
  would be ineffective and would cause those who
  know they are infected to go underground. If
  anything, this would merely increase the risk of
  infection spreading.
• A TB screening pilot ( 6 month period),
  Dover, tested around 5,000 asylum seekers and
  found no cases of symptomatic TB. However, they
  found evidence of maltreatment and torture -
  evidence of the reasons why people have fled
  countries and are seeking asylum.
• Preventing people from entering the country
  on health grounds to claim asylum would breach
  the 1951 UN Refugee Convention.

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Refugee Council
Amendment to clause 17 of the UK borders Bill
2007 which involves changes the definition of
asylum seeker for the purposes of support to
include those whose claims have been refused
while they are in the UK
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Defend Primary Healthcare
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Enforcing the Rules

• Home Office. Enforcing the rules a strategy to
  ensure and enforce compliance with our
  immigration rules. London Home Office, March
  2007.

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Enforcing the Rules

• Illegal migrants are unlikely to place a great
  strain on the NHS as most are thought to be young
  and therefore relatively healthy. However, there
  are some exceptions
• - There is evidence of small-scale but very
  deliberate abuse of the NHS. For example, a
  sampling exercise last year at one airport
  suggested that health tourists were being
  detected at the rate of about 15 per month. This
  primarily involved heavily pregnant women
  arriving in the UK with an intention of using NHS
  maternity services.
• - The threat of infectious conditions being
  brought into the country generates serious public
  health concerns. Since December 2006, visa
  applicants from 16 high-risk countries will be
  required to produce a certificate showing that
  they are free from infectious pulmonary
  tuberculosis.

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Enforcing the Rules

• Launched review we are concerned about
• Also includes some worrying aims...
• "To ensure that living illegally becomes ever
  more uncomfortable and constrained until they
  leave or are removed"

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Proposals to Exclude Overseas Visitors from
Eligibility to Free NHS Primary Medical Services
A Consultation

• "The aim of the proposals contained in this
  document is to ensure that the NHS is first and
  foremost for the benefit of residents of this
  country. We want to make it clear to overseas
  visitors that whilst they will continue to be
  entitled to receive emergency or immediately
  necessary treatment, free of charge, under these
  proposals they would not be eligible for other
  free NHS primary medical services. We would like
  to be similarly clear that failed asylum seekers
  will not be eligible for free routine NHS primary
  medical services. But we are equally clear that
  in putting forward these proposals, we will
  continue to meet our international obligations in
  providing care for genuine asylum seekers and
  others that have a legitimate claim to be offered
  free NHS primary medical services while in this
  country."

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Proposals to Exclude Overseas Visitors from
Eligibility to Free NHS Primary Medical Services
A Consultation

• Written a month after we lost secondary care
• Suggests rules will 'dovetail' with ID cards
• Response never published!
• DoH refuses to release submissions
• We are busy approaching individuals and
  organisations that made submissions (see
  medsin.org/ghap/asylum/2004consultation)?

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The Newham Health Impact Assessment

• Hargreaves S, Friedland J, Holmes A. The
  identification and charging of Overseas Visitors
  at NHS services in Newham a Consultation.
  London Newham PCT, June 2006

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The Newham Health Impact Assessment

• According to the 2001 Census, Newham is the
  most ethnically diverse place in the country
• Sally Hargreaves and her team surveyed GPs,
  Practice Managers, Overseas Payment Officers,
  community leaders, NGOs, etc
• Estimated that each month only 3000 worth of
  care was being accessed by potentially
  chargable people

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The Newham Health Impact Assessment

• Found widespread concerns about the
  administrative burden such legislation would
  cause
• Found many decisions on entitlement were
  being made by receptionists
• Concerns were raised that implementation
  would exacerbate existing racial inequalities
  and that the impact would be felt by both
  eligible and non eligible groups

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The Newham Health Impact Assessment

• In light of the broad scope of the
  organisational and procedural changes required
  for the effective
• implementation of the primary care proposals in
  Newham, and the limited financial burden that
• Overseas Visitors appear to be are having on
  primary medical services in the Borough, we
  conclude that the current proposals to streamline
  charging procedures at primary medical services
  with those in place at hospitals should be
  reconsidered.

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Joint Committee on Human Rights

• House of Lords and House of Commons Joint
  Committee on Human Rights. The
• treatment of asylum seekers. London The
  Stationery Office Ltd, March 2007.

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Joint Committee on Human Rights

• Chapter 4, on healthcare is devastating
• We have heard that the 2004 Charging Regulations
  have caused confusion about entitlement, that
  interpretation of them appears to be inconsistent
  and that in some cases people who are entitled to
  free treatment have been charged in error. The
  threat of incurring high charges has resulted in
  some people with life-threatening illnesses or
  disturbing mental health conditions being denied,
  or failing to seek, treatment. We have heard of
  many extremely shocking examples.

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Joint Committee on Human Rights

• We have seen evidence that the current
  arrangements for access to GPs result in the
  denial of necessary primary healthcare for many
  refused asylum seekers and their children. We
  believe that in many cases this is in breach of
  the ECHR rights to be free from inhuman or
  degrading treatment, to respect for private life
  and to enjoy Convention rights without
  unjustified discrimination, and also in some
  cases
• to the right to life.
• The Health Minister told us that that no
  information had been collected centrally about
  the costs and benefits of charging refused asylum
  seekers for secondary healthcare. We are
  concerned and very surprised that no steps are
  being taken to monitor the cost or effect of the
  2004 charging regulations in relation to the
  provision of secondary healthcare.

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Joint Committee on Human Rights

• No evidence has been provided to us to justify
  the charging policy, whether on the grounds of
  costs saving or of encouraging refused asylum
  seekers to leave the UK. We recommend that free
  primary and secondary healthcare be provided for
  all those who have made a claim for asylum or
  under the ECHR whilst they are in the UK, in
  order to comply with the laws of common humanity
  and the UKs international human rights
  obligations, and to protect the health of the
  nation. Whilst charges are still in place, we
  consider that it is inappropriate for health
  providers to be responsible both for (i) deciding
  who is or is not entitled to free care and (ii)
  recovering costs from patients. We recommend that
  a separate central agency be established to
  collect payments.

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Treat with Respect

• Gazzard B, Anderson J, Ainsworth J, Wood C. Treat
  with respect HIV, public health and
• immigration. London UK Coalition of People
  Living with HIV and AIDS, 2005.

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Treat with Respect

• The debate on public health and healthcare
  charging has centred on HIV
• ARVs are not exempt from charging
  regulations
• ARVs should reduce onwards transmission of
  virus both by lowering viral load, acting as an
  incentive for testing and by bringing people
  into contact with professionals who can
  support people in safe sex

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Treat with Respect

• 899 HIV-positive asylum seekers entered the UK
  between October 2003 and September 2004
• Providing ARVs to these 899 individuals, at a
  cost of 13.5 million per annum, would lead to
  a saving of between 500 million and 1 billion
  over an average lifetime by limiting both spread
  of the virus and other diseases associated with
  untreated HIV
• Treating HIV in groups affected by the 2004
  Charging Regulations is likely to be just as
  cost effective

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Health Tourism?

• Terrence Higgins Trust/George Health Trust.
  Recent migrants using HIV services in England.
  London Terrence Higgins Trust, October 2003.

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Health Tourism?

• Another nail in the coffin of the 'health
  tourism' myth
• Only 8 of 60 tested within 3 months of entry
• Most tested because they became unwell
  (58 27 of the 60 were severely ill)?

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Health Tourism?

• Other major reasons for testing were antenatal
  screening (17) and death or diagnosis of a
  partner (15)?
• Only 2 were diagnosed prior to entering the UK
  and only 1 on an unprompted visit to a GUM
  clinic

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Our Freedom of Information Requests

• Made to UCLH and United Bristol NHS Trusts
  and to the Department of Health
• Found that neither trust was recording
  mortality in the affected populations
• Found that United Bristol were employing 2 full
  time equivalent staff to implement the 2004
  secondary care regulations

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Our Freedom of Information Requests

• "I can inform you, however, that the majority of
  responses to the Consultation showed strong
  support for clarifying the rules. Beyond that,
  the responses were divided. There was much
  support for tighter rules and much support for a
  more inclusive and public health-driven approach.
  There was particular support for allowing failed
  asylum seekers (and dependants) to have access to
  primary medical services, taking account of their
  almost invariably poor economic position and
  their reasons for being in this country.
• We acknowledge that the existing rules regarding
  eligibility for primary medical services are
  unclear and leave much to the individual
  discretion of GPs and practices. That is why we
  undertook the consultation in 2004. The
  responses received highlighted a range of
  difficult and sensitive issues."

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Other Key Documents

• Case Studies
• Kelley N, Stevenson J. First do no harm denying
  healthcare to people whose asylum claims have
  failed. London Refugee Council, 2006.
• Destitution
• Refugee Action. The destitution trap research
  into destitution among refused asylum seekers in
  the UK. London Refugee Action, 2006.
• Project London
• Medecins du Monde. Helping vulnerable people to
  access healthcare. Project London Report 2006.
  London Medecins du Monde 2007.

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Other Key Documents

• European Comparisons
• Chauvin P, Parizot I, Drouot N, Simonnot N,
  Tomasino A. European Survey on undocumented
  migrants access to healthcare. Médecins du Monde
  European Observatory on Access to Healthcare.
  Paris Médecins du Monde, June 2007.
• Contravention of Human Rights Laws
• Hall P. Failed asylum seekers and healthcare. BMJ
  2006 333 10910.
• Its mostly Aussies, Kiwis and South Africans
• Hargreaves S, Friedland JS, Gothard P, Saxena S,
  Millington H, Eliahoo J, Le Feuvre P, Holmes A.
  Impact and use of health services by
  international migrants Questionnaire survey of
  inner city London AE attenders. BMC Health
  Services research 2006 6 153.

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What should be done?