Dr Louise Tomkow is a Geriatric Registrar in the Northwest deanery. She has recently completed a PhD, exploring migration and health at the Humanitarian and Conflict Response Institute. She will begin a 4-year Older People and Complex Health Needs NIHR Clinical Lectureship at The University of Manchester in April 2020. This blog accompanies her recently-published paper in the European Journal of Public Health.

• In 2017, the government extended the charges faced by migrants accessing healthcare.
• By asking migrants to prove their eligibility for NHS care and pay up-front before treatment, the government’s ‘hostile environment’ policies create borders within the NHS.
• Professionals and asylum seekers and refugees have a poor understanding of migrants’ eligibility for NHS care, making the 2017 extension to the NHS charging regulations a dangerous addition to vulnerable migrants’ already-problematic access to healthcare.
• In order to provide equitable safe healthcare and the benefits of better population health for all, we urge policymakers to revisit the 2017 charging regulations as a priority.

Context: Bordering in healthcare

Underpinned by a drive to decrease net migration, and as part of a series of ‘hostile environment’ policies, the government extended the charges faced by migrants accessing healthcare in October 2017. This means certain categories of migrant, including some refused asylum seekers, are asked to prove their eligibility for some NHS care and pay before treatment. Charging migrants for care up-front has been widely criticised on ethical, practical, fiscal and public health grounds. Importantly, however, emergency NHS care and General Practice remains free at the point of use for all.

Research shows asylum seekers and refugees face multiple barriers to accessing safe and effective healthcare in England. Specifically, there is concern that creating borders in the NHS amplifies the barriers to healthcare already faced by asylum seekers and refugees.  In parallel, there are questions about healthcare professionals’ knowledge of vulnerable migrants’ entitlement to care; no formal training for healthcare professionals about the new charging regulations has been introduced.

New research findings

We conducted a mixed methods study to jointly explore health care professionals’ awareness of migrants’ eligibility for healthcare, and asylum seekers and refugees’ awareness of NHS health services. The survey of health care professionals identified significant deficiencies in their awareness of migrants’ entitlements to NHS care.

Worryingly 36% of respondents did not know that all migrants are eligible for free emergency NHS care, irrespective of their immigration status. Only a small minority (6%) reported understanding the NHS charging regulations. In parallel, asylum seekers and refugees were found to have poor knowledge of their entitlement to free NHS care. As reported as reported in the British Journal of General Practice, migrants’ awareness appeared to be compounded by language difficulties, social isolation, insecure accommodation, and poverty.

Understanding and implementing the 2017 charging regulations is complex and time consuming. We suggest the regulations conflict with the General Medical Council’s recommendations for doctors. Delivering NHS services free at the point of use is a longstanding fundamental part of practitioners’ modus operandi. Many feel uncomfortable with the racial profiling risk inherent to establishing who is entitled to which care.

Policy recommendations

Our research shows there is impaired awareness of migrants’ eligibility for NHS care from both healthcare professionals and asylum seekers and refugees. Awareness is a fundamental facet of access; thus this lack of awareness represents a significant barrier to the provision of safe appropriate care. Providing accessible healthcare for marginalised populations benefits both individuals, population health and the care system long-term, including reduction of costly unscheduled care.

These findings also add to a body of literature that questions the moral, public health and fiscal implications of a policy that charges vulnerable migrants for healthcare and positions healthcare professionals as immigration officers. By highlighting significant deficiencies in healthcare professional’s awareness of asylum seeker and refugee’s (ASR) eligibility for NHS care we identify practical difficulties with the new regulations.

We conclude that the charging extensions represent a dangerous addition to ASRs’ already problematic access to healthcare. We urge health policy makers to revisit the introduction of ‘Hostile Environment’ policies into healthcare as a priority and recommend the following:

• The withdrawal of the 2017 Amendment Regulations.
• The exemption of refused asylum seekers from NHS charging.

This research also highlights the need to increase migrant populations’ awareness of how to navigate and negotiate the NHS. We recommend that health and immigration policy makers should:

• Develop and implement robust strategies to ensure new arrivals to the UK are provided with information about local health services in appropriate formats

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Healthcare access for asylum seekers and refugees in England: a mixed methods study exploring service users’ and health care professionals’ awareness.
European Journal of Public Health
DOI: https://doi.org/10.1093/eurpub/ckz193