Natal Nativism

Scene: the boardroom of a large NHS Trust, somewhere in England.

“And so that brings us neatly to the last item on the agenda: passport checks for pregnant women who want a checkup.  The thing is, you see, that it turns out that we’ve been providing obstetric care to some women who aren’t actually UK citizens.  And, clearly, that has to stop.”
“To stop?”
“Well, maybe not stop.  But you know what I mean.  We can’t go providing treatment to anyone who comes knocking at the door!  Why, we’d have a queue from here to Timbuktu, not to mention the cost!”
“Oh, quite.  No, I quite agree that we can’t be the world’s supplier of healthcare.”
“No.  So that’s settled, then.  No more obstetric services to women who can’t demonstrate their eligibility.”
“Hmmmm.”
“You don’t look convinced.  What’s the problem?  These women aren’t eligible.”
“Well, no.  But… well, look.  Remember when Dr Smith retired, and when Dr Jones got that transfer to work in the Inner Hebrides?”
“All too well.  Two great losses to the Trust.  What’s your point?”
“Well, I seem to remember that we pooled together to buy them nice leaving presents.”
“We did.  It was the least we could do.”
“I agree.  But, you see, the thing is, they weren’t actually entitled to them.  If you see what I mean.”
“I’m not sure I follow.”
“No.  Well, you see, the thing is, we bought them those presents, and gave them to them, because it’s the decent thing to do.  There’s no rule that says that we have to buy them.  They wouldn’t have been wronged if we hadn’t.”
“Yeeeeeeessssss…  I mean, no.  But yes.”
“But we gave them the presents anyway.  Because the rules set out what’s minimially decent.  Not an upper limit.”
“Yeeeeeesssss…”
“Well, you see, I was just wondering: might the same apply in other contexts?  Allowing for the obvious differences, of course.”
“You’re losing me again.”
“I thought I might be.  Well, you see, it’s like this.  We’ve been providing treatment to pregnant women without paying attention to whether they’re entitled by the strict letter of the law.  And that law specifies who is entitled to treatment.  But that doesn’t necessarily impose any exclusions.  You see, I wonder if by getting bogged down in the rules, we might… um…”
“Might what?”
“Well, you see, the thing is…”
“Go on…”
“Look: we might end up looking like utter shits.”

Wholly fictional, this, of course.  No such conversation took place.  On the other hand, as reported by the Beeb, here’s a document from St George’s University NHS Trust.  Skip to p80:

Obstetrics

The Overseas Patient Team and the Division are involved in devising a pilot study to ascertain what processes might be introduced to identify non-eligible women before receiving care.

The current practice is that patients are booked in and asked to complete a booking-in form. This form asks for proof of eligibility including passport details etc. However, these forms are routinely returned to the administration staff without these eligibility details completed and administration staff do not follow up on the missing information. The form is then kept until the woman has had her baby and then sent down in batches to the Overseas Patient Team for checking. This means that most, if not all, patients have to be sent a letter asking them to bring in documentation to prove eligibility. If they do not respond to the letter they are sent an invoice for their treatment at 150% as it is assumed they are not entitled.

Issues with this process include that women have already completed their treatment pathway and incurred significant costs prior to being identified as non-eligible, that large numbers of non-eligible patients are identified by default leading to increasing verbal and physical abuse and complaints, and that blanket invoicing incurred at a cost of £25 per invoice, generates additional costs only for the invoices, in most cases, never to be paid.

Hmmm.  Women who aren’t entitled to NHS care, in London.  Something tells me that a good portion of them will be here illegally or semi-legally.  Which is to say that they’re vulnerable, and probably pretty much on the breadline as it is, and yet the policy is to charge them not for the cost of their care, but for the cost of their care times one and a half, and to charge them £25 a pop for a letter… and then the Trust waxes indignant when that money isn’t paid.

You don’t say?

The pilot recommends a new way of working at the booking in process. Administration staff would be trained to check documentation (photo ID and current utility bill) which the women will be asked to present on booking. This will be advertised widely throughout primary care in preparation. […]

Anyone who was not able to prove eligibility would automatically be referred to the Overseas Patient Team for further investigation allowing real time management and identification of no [sic] eligible women.

The Home Office are keen to support this pilot as a way of benchmarking this process nationally.  […]  If this pilot study is successful the aim would be to roll it out across the hospital to safeguard all ‘front door’ access.

Ugh.  Vile.  Why did noone stick up their hand and say that this makes the trust look pretty shitty?

All this for the sake of what is estimated on p79 as £4-5m annually.  Not chicken-feed, for sure.  But… really?  It’s not much.  The UK is a rich country (still).  London is a rich city.  It’s highly unlikely to be the case that pregnant women who weren’t already in London are coming to London for the sake of a bit of obstetric care; so the idea that there’s an incentive doesn’t seem self-evidently convincing.  What is clear is that we have a group of people, members of which have other people actually inside their bodies; and those people and the people inside them presumably have needs and interests.

So, even leaving aside the possible costs of providing emergency care that might have been avoided if non-emergency care were available; even leaving that… really?

  • an immigrant

    And what about double charging of NHS fees? I have already paid £150 for the year in March when I came here and now had to pay another £200 in September for a year when applying for switching the visa. Will I get a refund? Think not.

  • Josh

    Nice description but I don’t think the analogy holds. It’s far from a bare difference. What you’re describing is like asking the department to club together and get a present for Dr A. However Dr A has never worked for the department, contributed to it, or even been known to it. You’d expect a little less generosity in those circumstances.

    It also happens that Dr A is female. In fact males don’t get any presents from the department. And even the females who do get presents are only the pregnant ones.

    And if you believe they have “..other people inside their bodies….” – which is open to debate – then there’s a very artificial demarcation:

    Why do those other people only get cared for when they’re pre-born? At what point would your generosity stop?

    Mrs X has a 40 week-old ‘person’ inside her. Mrs Y has a 40 week-old person who was born 3 weeks ago. I’m not clear where the morally relevant difference is that means we care for both Mrs X *and* her child, but we may not care for Mrs Y and her child.