Intended for healthcare professionals


Primary care for refugees and asylum seekers

BMJ 2006; 332 doi: (Published 12 January 2006) Cite this as: BMJ 2006;332:62
  1. Sally A Hull, senior clinical lecturer (s.a.hull{at},
  2. Kambiz Boomla, senior clinical lecturer
  1. Clinical Effectiveness Group, Barts and the London, Queen Mary's School of Medicine and Dentistry, London E1 2AT

    If the NHS stops free care for all groups, charities may offer the only safety net

    The decision by Médecins du Monde to open medical clinics in Tower Hamlets, east London, as an alternative to NHS primary care raises profound questions about society's attitude towards marginalised people.1 Médecins du Monde is best known for relief work in areas of disaster or war and in developing countries. Less well known are this non-governmental organisation's projects in European countries—more than 100 in France alone—for groups with restricted access to health care. Alongside its humanitarian clinical work, the organisation is committed to speaking out about social and political conditions in which its client populations live, and calling for changes to improve their circumstances.2

    Inequality in access to health services is not a new problem for east London, where inadequate recruitment and retention in general practice make access to the NHS difficult for the whole population.3 Médecins du Monde will focus on vulnerable migrants, including asylum seekers and refugees, and particularly on failed asylum seekers and other people staying longer than allowed. The difficulties faced by these groups in gaining access to primary care have been well documented.4 In much of Tower Hamlets, general practices are at full capacity or may be able to provide only temporary registration with doctors. People who try to seek health care often face language barriers at reception and in the consultation. Moreover, the effects of poverty, dependence on others, and lack of social support all affect these vulnerable people's health adversely.5 Not with standing this, the primary care trust has managed to avoid compulsory patient assignments to Tower Hamlets practices in the past nine months.

    Innovative methods of providing primary care to migrant populations and other groups who are difficult to reach, such as homeless people, already exist and continue to be developed within the NHS in east London, using personal medical services and alternative providers,6 so the provision of yet another source of primary care by Médecins du Monde is not really the point. What, then, will this organisation offer? The detailed findings of the organisation's needs assessment exercise have not been made public, but seem to suggest that vulnerable people in east London need better advocacy rather than more clinical care. Questions remain about the organisation's arrangements for basic clinical investigations and access to secondary care. In addition, staffing these clinics might divert scarce doctors and nurses from mainstream care to more fragmented and rudimentary provision while general practices might refuse to register patients, assuming that the project will provide care instead.

    Perhaps the main reason for the project is a tightening of the rules for eligibility to use the NHS. In August 2004 the UK government completed a consultation on “Proposals to exclude overseas visitors from eligibility to free NHS primary medical services,”7 aiming to align primary care with changes in April 2004 that required NHS trusts to charge overseas visitors for hospital treatment.8 After 16 months the government has not reached a decision, however, and responses to the consultation have not been published.

    Currently general practices have the discretion to register overseas visitors for NHS primary medical services, although such registration does not provide entitlement to referral for hospital care. Under the new proposals practices would have no discretion to register overseas visitors, failed asylum seekers, people who overstay their visas, and those without official papers, although the provision for emergency and immediately necessary treatment would remain. The consequences to health of restricting access to secondary care have not been scrutinised by the government, but anecdotal cases have highlighted concerns particularly about maternity care and management of HIV for such visitors. And confusion among some NHS staff about charging arrangements deters many people from seeking care to which they are entitled.9 10

    General practices do not have the resources or, in many cases, the desire to check patients' immigration status. The possible detriment to community relations might be considerable and the health consequences of denying primary care might be uneconomic, leading to emergency hospital admissions and pressure on accident and emergency departments. Most importantly, denying free basic health care to the most vulnerable groups in society, who are legally prevented from working and unable to pay charges, is ethically unsupportable and a breach of human rights.11 Indeed, denying such access to care may mean that general practitioners would be in conflict with their professional duties as doctors registered with the UK General Medical Council.12

    While access to free primary care remains an entitlement for refugees, asylum seekers, and all migrant groups, these rights should be advertised and provision of care should be improved through advocacy and support to practices. If the government persists with its proposals, however, the provision of services by charities and non-governmental organisations will become a necessity. We can only hope that the Secretary of State reviews this policy and ensures that the NHS continues to provide a service to everyone living in the United Kingdom.


    • Competing interests Both SAH and KB are GMS (general medical services) general practitioners in Tower Hamlets.

    • Analysis and commentp 115


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