Dr Louise Tomkow is a Geriatric Registrar in the Northwest deanery and a PhD researcher exploring migration and health at the Humanitarian and Conflict Response Institute, The University of Manchester. Dr Rebecca Farrington is a General Practitioner working with asylum seekers and refugees and a Senior Clinical Lecturer at The University of Manchester. In their blog they highlight how:

• the government’s ‘hostile environment’ policy creates borders within the NHS, with migrants being asked to prove their eligibility for some NHS care and pay up-front before treatment
• everyone, regardless of immigration status, is entitled to free primary care. New research published in the British Journal of General Practice shows that despite this, asylum seekers and refugees face difficulty accessing primary care
• this results in harm to patients, which is avoidable by providing inclusive basic care
• changes in public policy could improve the equity of health care provision.

The context: A hostile environment in the NHS

As part of the government’s drive to decrease net migration, the Immigration Acts of 2014 and 2016 make it increasingly difficult for certain migrants to access welfare services. These so-called ‘hostile environment’ policies embed a web of immigration controls into public services, including the NHS. The recent ‘Windrush’ scandal has highlighted the human cost of this punitive approach to immigration.

In October 2017, healthcare charging was extended. Now certain categories of migrant, including some refused asylum seekers, are being asked to prove their eligibility for some NHS care and pay up-front before treatment. This has been criticised by multiple parties, who cite moral objections as well as fiscal and public health concerns.

New research highlights barriers to accessing primary care

Although NHS general practice remains free for all regardless of immigration status, new research shows asylum seekers and refugees find it difficult to access. Despite many GP practices striving hard to provide equitable care according to need, the study shows this is often far from achieved, with worrying consequences.

Many asylum seekers and refugees described being asked for identification documents when registering with a GP. This contravenes existing guidance from NHS England and the BMA, and is a deterrent to seeking help. Worryingly, experiences of discrimination from NHS staff due to race, religion and immigration status were described.

Asylum seekers are not permitted to work in the UK. Instead they are provided with an asylum support allowance of £37.75 per person per week. Many participants reported that this was inadequate and left them unable to meet the costs of dental care, prescription charges and even public transport to GP appointments.

Asylum seekers and refugees described the provision of inadequate interpretation services; for some this resulted in them receiving invasive treatment in error. Many of the participants in the study lacked understanding about how to access NHS services. Some were unaware of how to call an ambulance in an emergency.

Providing patient-centred care for marginalised populations benefits both patients and the care system long-term, including reduction of costly unscheduled care. We urge healthcare providers to make use of existing resources to facilitate equitable access.

Policy recommendations

The study shows that there are barriers to accessing primary care, even when this care is provided free at the point of use. This raises serious concerns about healthcare access for some of the most vulnerable migrants and highlights the human cost of failing to provide good basic primary care.

Charging migrants for certain healthcare services creates another layer of bureaucracy for health care providers, who are already confused about which migrant groups are entitled to what care.

As such, we recommend the following:

• the withdrawal of the 2017 Amendment Regulations
• an independent inquiry into the 2015 NHS Charging Regulations should be conducted. This should focus on the impact on vulnerable groups and public health outcomes
• the exemption of refused asylum seekers from NHS charging.

The results also show the importance of the context of care and the wider determinants of health and healthcare access. Here, poverty emerged as a dominant finding from the data. The current asylum income support of £37.75 per week is 52% of income support levels for a single adult. We recommend:

• an increase in the rate of asylum support to at least 70% of mainstream income support.