Restricting access to the NHS for undocumented migrants is bad policy at high cost
BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h3056 (Published 16 June 2015) Cite this as: BMJ 2015;350:h3056
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We write with regard to the article in BMJ (20.6.2015) by Ginneken & Keith entitled "Restricting Access to the NHS for Migrants is Wrong".
Sadly this article demonstrates a lack of understanding of the facts. The authors fail to mention the Schengen Agreement signed by every EU/EEA country (other than UK and Ireland) which abolished passport and border controls at their common borders. Therefore these countries function as a single country for international travel purposes and have a common visa policy. It is an absolute requirement to have health insurance cover of at least €30,000 before a Schengen visa will be issued. In other words there is a mandatory structural link between immigration application and access to health services throughout the Schengen countries. The UK is not a signatory and therefore no mandatory health insurance is necessary to achieve a migrant or student visa to the UK which is why the Government, mistakenly, in our view is demanding the migrant and student visa surcharge. We have described this as the cheapest travel insurance on the planet and the cost is minimal compared to the health insurance required for a Schengen visa.
Furthermore the authors confuse undocumented migrants with "health tourists". That displays further misunderstanding. A health tourist is a person who arrives in the UK with a pre-existing illness and the purpose of their visit is solely to access free NHS care. Therefore health tourists should be considered in a separate category from illegal/undocumented migrants and asylum seekers.
The article mentions 618,000 undocumented migrants who "contribute to the economy through their employment…" but it is unclear whether this figure includes their dependents who will themselves need schools, housing, medical services etc.
As with other compassionate nations, asylum seekers cannot work but they receive a subsidy (£72.52 a week) as well as free accommodation, access to the NHS and schooling for their children. Illegal immigrants are not entitled to those benefits but they can get NHS care as GPs and A&E departments do not require evidence of "right of residency" before care is administered.
Health tourists, as stated above, are in an entirely different category. The cumulative invoices raised for health tourists is £500million but only 16% of this amount is recovered. Furthermore this estimate is based on the NHS tariff which is a fraction of the private tariff.
Add to the calculation the fact that most health tourists are difficult to identify or are exempt from payment for a variety of reasons and the undeniable conclusion is that health tourism costs £billions and not £millions.
Yours sincerely,
Liz Edmunds (former Immigration Officer)
J Meirion Thomas FRCS
Competing interests: No competing interests
Thank you for the responses. I would just add a few remarks to the discussion on the efficacy of provisions for testing and treatment of particular infectious diseases, such as TB, for undocumented migrants. Such provisions exist in several European countries, though unfortunately in a few countries only testing in available, and not treatment, which has obvious medical and ethical implications.
While certain services may be available to undocumented migrants in theory, there are persistent practical barriers which prevent migrants from accessing the care they are entitled to. These include, lack of awareness about undocumented migrants’ rights and procedures for their access to services, on both the part of migrants and providers; discretionary refusals of care; administrative requirements for certain documents (even if not immigration-related, these can be difficult for undocumented migrants to produce); and fear – and risk – of denunciation and deportation as a result of accessing services.
These barriers are more common and pronounced when undocumented migrants are only entitled to access very limited, specific services, and are not otherwise integrated into the public health system. So, another key factor determining the utility of provisions for certain infectious diseases is whether or not primary services are available. This is currently the case in the UK, but should charging be extending to primary care, it would directly undermine efforts to manage infectious diseases. Even if the provision of testing and treatment for certain diseases would be maintained free of charge, undocumented patients would have almost no engagement with the public health system, and so rarely be in a position to really benefit from these limited services. This is the reality we see across Europe.
It would also raise serious questions from a provider perspective, if you would only be able to provide treatment specifically for the infectious disease, and not for any co-infections or other health (and indeed, social care) needs the person may have.
Competing interests: No competing interests
Many thanks to Keith and Van Ginneken for highlighting this important issue. In support of their article, further recent research has shown that the introduction of fees for migrants is likely to impede health care access, infringes upon the international human rights agreement and results in delayed care which increases costs and threatens public health. Like Keith and Van Ginneken, interviewed experts suggest that the Immigration Act is simply a way of demonstrating that the Government is tough on immigration and is based on the false premise that health tourism presents a significant burden to the NHS [1].
Furthermore, health care access is a key indicator of a migrant's integration into the host society. Much of the research on health inequality which feeds into health policy focusses on black and minority ethnic groups, many of whom have been living in the UK for some time or are born here. The specific needs and experiences of migrants and, in particular recent migrants, need to be considered in addition to evaluation based simply on ethnicity [2].
Early findings from my own research exploring access to health care amongst migrants with tuberculosis indicate that whilst TB treatment remains free, concerns over the need for appropriate documentation stops irregular migrants from seeking help, resulting in the risk of increased spread of the disease in the community, not to mention increased morbidity and mortality for the individual and costs to the NHS as a whole.
Not only has this government introduced measures to restrict health care access to migrants, they have also made changes that stop migrants from claiming certain benefits [3]. For patients with tuberculosis, the failure to integrate health and social care access results in higher costs and negatively impacts on public health [4]. Therefore, alongside the authors’ suggestion that the UK government should ditch the Immigration Act and instead ‘explore ways to provide non-discriminatory access to the NHS for all’ I would also advocate extending this to social care.
Clearly providing accessible health care to this often vulnerable group of people is morally the right thing to do. However, we are going to need more compelling evidence in if we are to convince the government that it is also cost effective and in the best interests of this country and its inhabitants.
1 Britz JB, McKee M. Charging migrants for health care could compromise public health and increase costs for the NHS. J Public Health (Oxf) 2015;:fdv043 – . doi:10.1093/pubmed/fdv043
2 Jayaweera H. Health and access to health care of migrants in the UK. Better Heal Brief 2010.
3 UK Government. New rules to stop migrants claiming housing benefit. Gov.uk. 2014.https://www.gov.uk/government/news/new-rules-to-stop-migrants-claiming-h...
4 Potter JL, Inamdar L, Okereke E, et al. Support of vulnerable patients throughout TB treatment in the UK. J Public Health (Bangkok) 2015;:1–5. doi:10.1093/pubmed/fdv052
Competing interests: No competing interests
My thanks to Keith and van Ginneken for their excellent article. Of course, it is obvious to most of us that this appalling policy was a response to the governments perceived need to crack down on nasty foreigners, under pressure from UKIP - a nasty and entirely political move, unsupported by economic, let alone medical evidence.
I would like to point out that - as far as I know, and perhaps only in theory - Keith and van Ginneken's concerns about a lack of access to services risking outbreaks of infectious diseases is mitigated by the fact that treatment of certain infectious diseases is still exempt from charges for public health reasons.[1] (Unless newer legislation that I'm not aware of invalidates this. I wouldn't put it past this government to have introudced such legislation - by mistake, if not deliberately).
I agree, however, that few people seem to be aware that such treatment is available without charge, and that it is less clear (as far as I'm aware - perhaps somebody reading this can enlighten me!) whether prevention (such as screening for TB on entry from a high prevalence country), as opposed to treatment, is supposed to be available without charge.
Peter English.
1. Department of Health International Health and Public Health Policy Division. Guidance on implementing the overseas visitor hospital charging regulations 2015: Department of Health, International Health and Public Health Policy Division, 2015 (25 March); 1-233.
Competing interests: No competing interests
Great article. Good to see a policy shown up for being politically driven rather than being evidence based. Again this shows that policy makers are often not thinking of the bigger picture and shows a lack of understanding of the usefulness and role of Primary Care in preventative medicine. Research in the British Journal of General Practice last year clearly suggested that poor access to Primary Care is associated with increased A&E attendances.(1) With the evidence in this paper showing that Sweden found providing health services to migrants was cheaper than expected and Spain making a U-turn and allowing access to Primary Care again - is it time for the UK government to do the same?
1 - Access to general practice and visits to accident and emergency departments in England: cross-sectional analysis of a national patient survey
Thomas E Cowling, Matthew J Harris, Hilary C Watt, Daniel C Gibbons, Azeem Majeed
Br J Gen Pract Jul 2014, 64 (624) e434-e439; DOI: 10.3399/bjgp14X680533
Competing interests: No competing interests
Re: Restricting access to the NHS for undocumented migrants is bad policy at high cost
If, as you say, the health tourists are the ones who come into the UK, usually on a visitor's visa, with the sole intent of accessing NHS services for a pre-existing health condition, how does charging the UK resident who is working and paying taxes and needs to extend their visa prevent health tourism? How does charging the student who is going to pay double or triple the fees that a UK student would pay for the same course tackle health tourism?
At the end of the day, this surchage is a misinformed knee-jerk reaction to the UKIP voters that victimises the wrong people while the health tourists continue to gleefully avail themselves of NHS care at whatever cost to the government.
Competing interests: I am a doctor and a migrant and my family pays for private healthcare if it is needed when they come to visit