DEFEND PRIMARY HEALTHCARE

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DEFEND PRIMARY HEALTHCARE

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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

• SI No 614
• Removal of access to secondary care predicated
  on the idea of Health Tourism
• Affected groups are...
• failed asylum seekers awaiting deportation
• failed asylum seekers receiving Section IV
  support
• undocumented migrants

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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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Health impact of current policy

• The 2004 regulations and ensuing confusion have
  resulted in desperate cases of people unable to
  access health care for serious or life
  threatening illness.
• Sometimes because they are unable to find the
  funds required to pay for treatment or because
  they are so scared of the possibility of debt
• First do No Harm denying health care to people
  whose asylum claims have failed (Kelley N,
  Stevenson J. 2006).

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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

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Organisations involved in the healthcare of
asylum seekers and refugees
Employment
Voluntary organisations
Refugee communities
Education Services
Religious organisations
Dentists
Organisations
Housing services
Health professionals
Social services
National Asylum Support Service (NASS)
Legal organisations
Services for survivors of torture and rape
Mental health services
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Remember access to services is not just about the
law...
Staff shortage within a health team e.g. Mental
health teams.
Lack of awareness of available facilities. Unsure
what going to the doctors involves
Communication barriers
GP quota
Cultural/ ethnic barriers
Lack of a fixed postcode/ asylum status and
pre-occupations
Factors influencing access to healthcare
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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Our FOI 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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Project London 2007 Report

• East London clinic, run by Medecins du Monde.
• Provides healthcare to vulnerable groups
  including people whose visas have expired,
  refused asylum seekers and irregular entrants to
  the UK.
• We saw numerous asylum seekers and EEA citizens
  who were denied access to primary care despite
  the fact that they are entitled both under the
  current law and the proposed law.

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Project London 2007 report

• The majority needed help to access primary care
  or antenatal services rather than expensive
  specialist treatment.
• Ninety percent of pregnant women accessing
  Project London services were not registered with
  a GP.
• Despite the well known risks of mother to child
  transmission
• of HIV/AIDS, only 25 of pregnant women had had
  access to antenatal HIV screening.
• The project helps service users register with a
  GP after an appointment at the clinic. Even after
  a registration appointment was made, follow-up
  was often necessary due to
• barriers caused by language
• barriers caused by misunderstandings
• barriers caused by inhospitable and sometimes
  hostile
• GP surgery staff
• barriers caused by surgery staffs lack of
  knowledge and understanding of the regulations.

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What about primary care?

• BMA Guidance September 2008
• All asylum seekers are entitled to free primary
  health care, including those who have been
  granted Discretionary Leave to Remain or
  Humanitarian Protection.
• Emergencies, treatment which is immediately
  necessary, including maternity services,
  treatment of certain specified communicable
  diseases (e.g. TB), and compulsory mental health
  treatment should be provided free of charge
  within primary care to all asylum seekers and
  refused asylum seekers, where clinical opinion
  judges this is required.
• All asylum seekers have the right to be
  registered with a GP practice.
• Health professionals must not discriminate
  against asylum seekers or unfairly prioritise
  other patients in preference to them.
• Failed asylum seekers and asylum seekers who are
  not receiving benefits may still be entitled to
  free prescriptions.
• GP practices retain the discretion to register
  failed asylum seekers, to the same extent that
  they have this discretion in relation to
  registering any patient, regardless of
  immigration or residency status.

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Proposals to Exclude Overseas Visitors from Free
Primary Care Services (May 2004)

• "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 Free
Primary Care Services A Consultation

• Written a month after we lost secondary care.
• Response never published!
• DoH refuses to release submission (More about
  that later)

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Enforcing the Rules

• 2007 Cross-Government Enforcement Strategy
• suggests that primary care will be brought into
  line with existing secondary care regulations.

Home Office (March 2007). Enforcing the rules. A
strategy to ensure and enforce compliance with
our immigration laws.
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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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Ongoing review of access

• The DoH and the Home Office are currently
  conducting a review of access to primary
  healthcare services for overseas visitors.
• The report has been delayed several times and
  looks to be further delayed due to a recent
  judicial review that disputes healthcare rights
  for refused asylum seekers.
• Many previously denied access to NHS services now
  come under the category of ordinarily resident
  and are therefore entitled to healthcare.
• The DOH have placed and appeal, which will go to
  court in November 2008.

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Why does the DOH want to remove care?

• To save the NHS money?
• To combat health tourism?
• A lever of immigration policy?

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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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Health Tourism?

• The Government itself has stated there is no
  evidence of significant levels of health tourism.
  
• BMJ the average physical health status of
  asylum seekers on arrival is not especially poor,
  when compared to the average fitness of UK
  residents. However, there is evidence to suggest
  that the health status of new entrants may worsen
  in the two to three years after entry to the UK.

Home Office (March 2007). Enforcing the rules.
A strategy to ensure and enforce compliance with
our immigration laws. Johnson M (February
2005). Evidence to Third Report from the Health
Committee patient and public involvement in the
NHS. Question 211.
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Health Tourism?

• Since 2004, there seems to be a shift of intent
• Protection of NHS resources, or deterrence from
  illegal residence?
• living illegally becomes ever more uncomfortable
  and constrained until they leave or are removed.
• Home Office (March 2007). Enforcing the rules. A
  strategy to ensure
• and enforce compliance with our immigration laws.

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What are the implications of denying access to
primary care?

• Human rights
• Impact on Health
• Public health implications
• Administrative burden
• Inappropriate use of NHS services and flooding of
  AE
• Professional ethics
• Cost effective? (20 for a GP appointment vs.
  110 for AE)

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Human Rights

• Universal Declaration of Human Rights
• European Convention on Human Rights
• International Covenant on Economic, Social and
  Cultural Rights (ICESCR)
• the proposed changes will be open to legal
  challenge unless general practices and other
  primary care services are permitted to provide
  free NHS treatment in circumstances which would
  otherwise give rise to a breach of the European
  Convention on Human Rights.
• Immigration Law Practitioners Association

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Joint Committee on Human Rights(The treatment of
asylum seekers tenth report of session 2006-7,
2007).

• 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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Impact on health

• An estimated 86 of all UK health needs are met
  in primary care by GPs.
• Newham PCT have completed the only health impact
  assessment of the proposals.
• Their findings indicate that the primary care
  proposals are unworkable in Newham at this time.

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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.
• 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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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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Maternal Health

• Vulnerable migrants are at particular risk of
  maternal deaths and infant mortality. (CEMACH
  report 2007)
• All antenatal, birth and postnatal care is to be
  considered immediately necessary. This does not
  mean that it is free.
• Evidence suggests that the arrangements for
  levying charges has led to the denial of
  antenatal care to vulnerable women (Joint
  Committee on Human Rights, The treatment of
  asylum seekers tenth report of session 2006-7,
  2007).
• See Medacts briefing on Maternal Health

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Other Health Concerns

• Emergency care
• Psychological care and trauma
• Lack of alternative services

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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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General Medical Councils Duties of a Doctor

• Make the care of your patient your first
  concern

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Freedom of Information

• Freedom of Informationcan be inconvenient, at
  times frustrating and indeed embarrassing for
  governments.
• Gordon Brown, 27 October 2007
• Responses to 2004 consultation never published
  (Proposals to Exclude Overseas Visitors from
  Eligibility to Free NHS Primary Medical Services)
• We used the FOI Act to request access to these
  responses.
• ACCESS DENIED!

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www.WherestheConsultation.com

• We were given a list of 275 names of those who
  responded.
• We contacted as many as possible to request a
  copy of their submission and put together a
  summary of the responses we were able to obtain.
• With the help of the Refugee Council, our report
  has since been publicised in the BMJ, the
  Observer and the BBC.
• Sent to MPs, interested organisations, individuals

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Results of the consultation

• 97 of the responses we collected raised at least
  one concern about the proposals.
• 75 of submissions from healthcare providers
  expressed concern that denying care would place
  them in breach of their professional code of
  conduct.
• 68 had public health concerns (delayed detection
  and treatment of infectious diseases)
• Majority felt refused asylum seekers, settled in
  the UK, were not overseas visitors, rather they
  were a vulnerable group who should not fall
  within the scope of the proposals.
• 87 raised concerns over the workability of the
  proposals.
• 55 were concerned about cost-effectiveness.
• Discrimination? Marginalisation? Damage public
  perception of migrant communities?
• Some that were broadly supportive expressed
  concerns that proposals lacked clarity.

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What do we believe?

• That destitution should not be used as a lever of
  immigration policy.
• That all those who live in the UK should be
  entitled to free NHS care until the point that
  they leave or are removed.

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What Next?

• Branch involvement
• Education and raising awareness
• Monitoring the media
• Borders and immigration bill
• Result of judicial review
• Report on ongoing DOH review and consultation
• Preparation for future changes in legislation
• Campaign for access to primary and secondary care
  for refused asylum seekers and irregular
  migrants.

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In other news

• Meeting in Parliament
• Medact petition
• EDM
• Judicial Review and DOH appeal (implications for
  primary care)
• New Statesman No Place for Children Article and
  petition
• Home Affairs Committee enquiry and New Borders
  and Immigration Bill

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What can you do?

• 2 minutes
• Sign the Medact petition
• Join the mailing list
• 2 hours
• Write to your MP
• Talk to your MP
• Medical students on placement
• Write an article for a student/local lpaper
• 2 weeks
• Organise a talk at your Medsin branch
• Longer term
• Talk to us about joining the campaign group in
  the long term
• We are working with Crossing Borders
• Doctors, NGOs, organisations working with
  refugees and asylum seekers etc.
• Respond to consultation

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www.medact.org ? Refugee Network ?
Entitlement www.Medsin.org/DefendPrimaryHealthcare
www.Wherestheconsultation.org