Transferring healthcare for immigration detainees in England to the NHSBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1884 (Published 22 March 2013) Cite this as: BMJ 2013;346:f1884
- Hilary Pickles, public health adviser ,
- Naomi Hartree, medical adviser
Of the organisational changes that will come into force on 1 April 2013, one is most welcome. The NHS in England will become responsible for the healthcare of people detained in all immigration removal centres. This change could improve services for a vulnerable group of patients. Until now, healthcare provision for those detained under the Immigration Act has mostly been provided by private companies contracted to the UK Border Agency—in effect, a backwater of publicly funded healthcare that many would describe as failing. From April, the NHS Commissioning Board becomes responsible for the contracts, alongside those for healthcare in prisons. This has been a long time coming.
Asylum seekers and “irregular” migrants (those without a valid visa) can be held in immigration removal centres indefinitely while their cases are determined. For asylum seekers, this may occur at any stage of the asylum process, but mostly at the start (if claims are “fast tracked”) or at the end (if the asylum claim has been refused). The number of places for detainees has increased in the past two decades from 250 in 1993 to more than 3200. Private companies run over 70% of these centres, whereas the remainder fall under the prison service. About 600 more detainees are held in prison—some, but not all, after a custodial sentence has been served. For those detained under the Immigration Act no limit is given to the length of detention. In a system devised to hold detainees for a few days, many stay for weeks or months, some even for years. Immigration officers make the decision to detain, with no judicial approval or oversight.
Standards of healthcare in immigration removal centres are meant to match those in the NHS. Currently, however, that is often not the case within private centres—there has been severe criticism from detainees, commentators, lobby groups, external inspectorates, and the courts.1 2 3 4 5 6 This is a national shame that has attracted little comment in the media. Hard evidence of improved healthcare in prisons after they came under the umbrella of the NHS a few years ago is lacking, but many consider prison medical services to have improved. The expectation is that coming under the NHS will help raise standards of healthcare in immigration removal centres too.
At the very least, transfer of healthcare to the NHS means that services for these vulnerable people will enjoy the relative stability of “ring fenced” NHS budgets, rather than being exposed to the severe cutbacks being experienced in the UK Border Agency. Healthcare complaints procedures should fall into line with the rest of the NHS; currently, these people—who are mostly ineligible to register as voters—have no external complaints process, except through an MP. The current system of clinical record keeping, which in some centres is outdated or inadequate, can be brought up to date, which will lift one of the barriers in health communication with NHS providers. Standards for healthcare services in centres will be overhauled and an inspection system in common with the NHS will be instated.
There has been no national health needs assessment for immigration removal centres of the sort that took place before prison healthcare was transferred to the NHS. If one had been done, mental illness would probably have been identified as the area of biggest mismatch between need and current provision. A high proportion of detainees exhibit mental distress or frank mental illness, exacerbated by the uncertainty of their indeterminate sentence.7 8 Mentally ill detainees are often at high risk, including from suicide.
Theoretically, those with mental illness should not be detained except under exceptional circumstances. Although practitioners can appeal against patients’ detention (under rule 35 of the UK Border Agency’s enforcement instructions) this provision is underused or ignored.9 10 Thus, patients such as torture survivors or those with florid psychosis often continue to be detained despite doctors’ opinions that detention is harming their health. In addition, doctors working in a custodial setting may have competing loyalties.11 The most obvious solution for people who are mentally ill is to find alternatives to detention. Temporary release of these people into the community would be a politically courageous potential solution. It would do away with the adverse impact that incarceration itself has on mentally ill detainees, and it would enable easier access to a full range of NHS services.
Another problem with the care of mentally ill detainees is a lack of clarity over responsibility for secondary level mental health services. Immigration removal centres generally contract private psychiatrists for secondary care. This has resulted in inadequate services, not least because such services are not well supported by a wide range of community mental health services as in the NHS. Bringing detainees’ healthcare services under the NHS will improve the provision of secondary mental health services. Robust commissioning is now needed in the transition process so that detainees can benefit from seamless care in the new NHS funded service.
Anyone compulsorily detained in the UK should have the right to the full range of NHS services without charge, and to the usual standards of NHS care. The transfer of responsibility for healthcare from the UK Border Agency to the NHS should make this happen for immigration detainees. However, careful monitoring of the impact of transfer to the NHS is needed, even though evaluators will be handicapped by a lack of robust “before” data. In this area, at least, the NHS Commissioning Board could make a real difference for the better.
Cite this as: BMJ 2013;346:f1884
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: Medical Justice is a charity advocating for better healthcare for immigration detainees in the UK, for which HP does limited pro bono work and NH does limited paid work
Provenance and peer review: Not commissioned; externally peer reviewed.