Legal Update: NHS cost recovery proposals
Gargie Ahmad
Tuesday, December 6, 2016
Patients may soon need to present identification to access NHS treatment. Gargie Ahmad, intern at Coram Children's Legal Centre, considers the impact on undocumented migrant children and families.
As part of a strategy to improve efficiency and productivity in the NHS, the UK government has recently increased its focus on recovering costs from overseas migrants and visitors who receive secondary care treatment through the NHS. This includes maternity care and urgent care for non-life threatening illnesses required the same day. In October, the National Audit Office (NAO) published a report outlining that the government's ambition of recovering up to £500m a year by 2017/18 faces a shortfall in the region of £150m under the current charging regime.
Potential plans to meet the projected shortfall include asking patients to present a passport and proof of address in order to receive treatment. These measures are already being piloted in some NHS England Trusts.
However, there are concerns that these proposals are not grounded in sufficient evidence, are discriminatory against migrants, and may lead to negative impacts against people who are most in need, particularly children.
Undocumented migrants are often marginalised, vulnerable to abuse and exploitation, and have poor health outcomes. In 2012, it was estimated that there are 120,000 undocumented children in the UK, more than half of whom were born here.
Flawed evidence behind the proposals
There is substantial uncertainty about the figures behind the controversial plans. The NAO report recognises that it is difficult to know how much money the NHS should be charging and recovering for treating overseas visitors and migrants because the existing data is incomplete and unreliable. Further, there is lack of understanding of the costs that NHS Trusts can incur in pursuing these measures; in some cases, there is potential for the recovery costs to exceed what is recovered.
There is a worrying misinterpretation among NHS staff about entitlement to secondary care, available to all those "ordinarily resident" in the UK. It is difficult, if not impossible, to identify entitlement simply from a passport and proof of address. Patients from black or minority ethnic communities, or those who do not speak English fluently, may face discrimination and be particularly targeted for checks. According to qualitative research conducted in 2013, as many as 30 per cent of patients assessed by trusts were incorrectly classified, resulting in charges for people who were actually entitled to free care.
A secondary aim of these proposals is to deter so-called "health tourists" from coming to the UK. However, evidence of the existence of health tourism is vague and inconclusive. Where there is evidence, what it suggests is that the average use of health services by immigrants and visitors is lower than that of people born in the UK. There are also cost implications for reducing access to healthcare: providing access to regular preventive healthcare reduces the risk that a person only presents for treatment in a crisis situation.
Many have expressed serious concerns about the unsustainability and appropriateness of the plans, arguing that the proposals are too "broad brush" for the scale of the issue. The British Medical Association has condemned the plans as going "much too far", given that the estimated amount of money unrecovered from overseas patients is very small in proportion to the size of the funding deficit that the NHS is suffering overall. There is lack of clarity on any viable implementation strategy for these proposals, which could place unnecessary responsibilities and further pressure on already overstretched NHS staff.
Adverse impact on the most vulnerable
In the current climate, access to primary NHS care that is free and accessible by all regardless of immigration status is already challenging for migrants. The Department of Health itself recognises that undocumented migrants, and people with no recourse to public funds, are already extremely vulnerable to ill health. Some groups, such as pregnant women who are recent migrants, face higher risks of adverse pregnancy outcomes than the general population, and there are concerns among professional bodies that further barriers would pose a serious threat to the health of both mother and baby.
Opponents to the proposals, including the BMA and the RCN, argue that healthcare professionals should not be expected to act as border guards. It is clear that the evidence gaps behind the plans are stark and that the Department of Health should review research that demonstrates how providing access to regular preventive healthcare for migrants in an irregular situation would be cost-saving for governments. In the end, the Department of Health is committed to reducing inequalities by improving the health outcomes of all groups, including the marginalised and vulnerable. These cost recovery proposals are unlikely to contribute to the achievement of that aim.
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Legal Update is produced in association with experts at Coram Children's Legal Centre www.childrenslegalcentre.com
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