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Editor's Choice

Boundary crossings

BMJ 2013; 347 doi: (Published 30 October 2013) Cite this as: BMJ 2013;347:f6556
  1. Giselle Jones, specialist reviews editor, BMJ

The UK government’s new Immigration Bill has caused ructions among politicians, health economists, and the medical profession. The resulting fallout continues to smoulder, but it is often fuelled by perception rather than fact. John Appleby (doi:10.1136/bmj.f6483) presents the facts about the costs to the NHS of treating non-UK residents, the proposed changes in the bill, and how much money they might save. Theoretically the proposals could increase NHS revenue by £500m (€585m; $807m), but will they in practice? “Well, it’s possible,” Appleby says. “But there are many uncertainties.” The crux of which seems to be the government’s admission that “a fundamentally different system and supporting processes” would be needed. It doesn’t sound easy, or cheap—in her Editorial, Johanna Hanefeld and colleagues say that the administrative cost of collecting this money is about £3m over 10 years (doi:10.1136/bmj.f6514).

More importantly, is it necessary to restrict access to health services by migrants? Sophie Arie (doi:10.1136/bmj.f6444) unpicks whether European migrants are the drain on resources that they are perceived to be. According to the 2013 International Migration Outlook report, “the fiscal impact of immigration is close to zero” and “most immigrants do not come for social benefits, they come to find work and to improve their lives.” Despite the government’s assertions about the cost of so called health tourism, accurate data are hard to find. But recent research suggests that Britain actually exports more health tourists than it imports. Many other EU countries’ policies are more stringent than the UK’s, made possible because of the fundamental difference in how patients pay for services. Patients pay upfront, then claim back the costs through social security and insurance programmes. So it seems that the founding principle of the NHS—being free to everyone at the point of care—is ultimately the source of its current predicament.

Crossing geographical boundaries is not all the NHS has to worry about. According to a senior female doctor, crossing personal and professional boundaries is also a problem. She describes her experiences of sexual harassment as a junior doctor, and being regularly criticised and humiliated by male consultant surgeons (doi:10.1136/bmj.f6302). One “made an offensive remark about the size of my breasts.” Despite her rage and humiliation, she just bit her lip “suppressed the tears, and carried on.” Why? “I did not speak up because I did not know where to go for support. Would I have been labelled as a pathetic woman who could not take the heat?” Such experiences are by no means limited to the NHS; the BBC has recently announced it will review sexual harassment allegations that came out of the Respect at Work report. The NHS would be wise to follow the BBC and survey the extent of the problem within its organisation.

This week we launch the annual BMJ awards. Details of categories and how to enter are at (doi:10.1136/bmj.f6515).


Cite this as: BMJ 2013;347:f6556


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