Timely access to healthcare depends on individuals recognising that they need clinical care, knowing that they are entitled to that care, and trusting the healthcare system and individuals which provide it. For many migrants living in marginalised situations in England, this is not the case. Doctors of the World report that 1 in 3 of their service users were deterred from seeking timely care.  Examples of delay include not attending the emergency department following a workplace eye injury, not presenting when finding a breast lump, or not attending a community clinic for ante-natal care.
Peoples’ fears of accessing healthcare are rooted in two Government policies: charging regulations and data sharing. NHS England amended charging polices for NHS care in 2015 and 2017, increasing restrictions on access to a range of health services for overseas visitors.  Although certain services remain free at point of use, for example, seeing a GP, treatment deemed urgent or immediately necessary, care for certain exempt conditions (e.g. priority infectious diseases, or because of torture, domestic violence or trafficking), family planning services (though not terminations or maternity services) or services provided through NHS111, many migrants, or healthcare staff are not aware of this.  Many may also have heard media reports about patients who are entitled to care, but have had it denied.  Even when migrants are aware of their eligibility for general practice care, they are asked to produce documents such as proof of address, which are not required for registration. This lead to a Safe Surgeries campaign by Doctors of the World, which aims to improve access to healthcare for migrants. 
Beyond these exceptions, hospital and community-based care is now subject to charges.  These providers of care are legally required to check patients’ entitlement to services before treatment. “Overseas visitors” who are not ordinarily resident in the UK (e.g. short-term visitors or migrants without permission to be in the UK, and some asylum seekers whose asylum claim has been refused) are required to pay, and are charged up front at 150% tariff. Disquiet among healthcare workers about being asked to check patients’ status has led to the “Docs Not Cops” campaign.
Sharing of non-clinical data collected by the English NHS with immigration authorities was implemented as a means to increase deportations of those deemed to be contravening immigration law, part of a wider policy to create a “hostile environment” for migrants.  It was based on a Memorandum of Understanding (MoU) signed by the Home Office and NHS Digital.  Following a campaign by clinicians, organisations providing care for migrants, Royal Colleges, and an inquiry by the Health and Social Care Select Committee, this MoU was abandoned. A new MoU is reportedly being drafted. In the meantime, however, data sharing continues through other mechanisms, including reporting of patients with an NHS debt of over £500 after two months to the Home Office.
A comprehensive assessment of both the health and equality impact of these changes is needed. The Equality and Human Rights Commission have recently documented the barriers that migrants face accessing care, and there are numerous examples of individuals who have been affected. [10-11] Such evidence is needed to quantify the scale and nature of inequality and to ascertain the consequences of vulnerable patients being “left behind” in terms of access to timely and appropriate healthcare. The UCL-Lancet Commission on Migration and Health called for governments to ensure universal and equitable access to healthcare for all migrant populations. 
Denying access to healthcare can, ultimately, result in poorer and more costly health outcomes, and higher health system expenditure.  However, assessing the full impact of restricting access requires good quality data, and transparent evidence-based policy making. Currently, this is sadly lacking in England. The Government commissioned a review into the impact of the 2017 charging regulations, but has not published its findings, despite stating that there was no evidence that such charges had deterred patients from seeking care.  Likewise, neither a review from Public Health England into the impact of the data sharing agreement on help-seeking behaviour and health outcomes or an evaluation of a pilot study testing the impact of asking for patient identification in hospitals have reported yet.  This has led to a call from the Academy of Medical Royal Colleges, MPs, provider organisations and academics for greater transparency on the impact of these policies on health care and an immediate release of these reports. 
Of course, care does not have to be restricted in this way. In Scotland and in Wales, a different approach is being taken. There, “refused” asylum seekers and migrants whose status is deemed “irregular” have the same rights and entitlements to health care as the general population. [16,17] Currently, there are no routine data which allow us to explore the impact of these different, more inclusive and supportive, policy approaches to providing healthcare. A recent systematic review reported that policies restricting welfare entitlements increased the likelihood of poor self-rated health and mortality.  We propose that, in the absence of such data, approaches in Scotland and Wales demonstrate that the provision of healthcare can be separated from migration policy and align with the principles of ensuring universal healthcare coverage for all. This should not only be welcomed, but strongly encouraged.
Kate O’Donnell is professor of primary care R&D, University of Glasgow, and co-chairs the Scottish Migration and Ethnicity Research Strategy Group.
Ibrahim Abubakar is director of the UCL Institute for Global Health, Professor of Infectious Disease Epidemiology and he chaired the UCL Lancet Commission on Migration and Health.
Rob Aldridge is a Wellcome Trust Clinical Research Career Development Fellow at the Institute of Health Informatics.
Jon S Friedland is Deputy Principal at St George’s, University of London, and has a very long standing research interest in migrant health.
Sally Hargreaves is a Lecturer in Global Health at St George’s, University of London.
Martin McKee is Professor of European Public Health at the London School of Hygiene and Tropical Medicine.
Miriam Orcutt is a Migration Health ESRC Fellow at the Institutte for Global Health, University College London and a medical doctor.
Philomene Uwamaliya is a registered mental health nurse.
Laura B Nellums is a lecturer in Global Health at St. George’s, University of London, with a research focus on disparities in access to care and health outcomes in migrant populations.
The authors are all members of the Doctors of the World Expert Consortium on Refugee and Migrant Health, but have written this opinion piece in their own academic roles.
- Doctors of the World. Deterrence, delay and distress: the impact of charging in NHS hospitals on migrants in vulnerable circumstances. London: Doctors of the World, 2017.
- Hiam L, McKee M. Upfront charging of overseas visitors using the NHS. BMJ 2017;359:j4713 doi: 10.1136/bmj.j4713[published Online First: Epub Date]|.
- Department of Health & Social Care. Guidance on implementing the overseas visitor charging regulations. London: UK Government, 2019.
- Campbell D. Migrants wrongly told to pay for NHS care upfront, minister admits. The Guardian 2019 17/2/19.
- Bates E. Safe surgeries: how Doctors of the World are helping migrants access healthcare. The BMJ Opinion: BMJ, 2019.
- Doctors of the World. Briefing on amendment of the National Health Service (Charges to Overseas Visitors) Regulations 2015, 2017.
- Hiam L, Steele S, McKee M. Creating a ‘hostile environment for migrants’: the British government’s use of health service data to restrict immigration is a very bad idea. Health Economics, Policy and Law 2018;13(2):107-17 doi: 10.1017/S1744133117000251[published Online First: Epub Date]|.
- Gulland A. Handing NHS data to the Home Office. BMJ 2017;356:j911 doi: 10.1136/bmj.j911[published Online First: Epub Date]|.
- Health and Social Care Committee. Memorandum of understanding on data-sharing between NHS Digital and the Home Office. London: House of Commons, 2018.
- Equality and Human Rights Commission. Making sure people seeking and refused asylum can access healthcare: what needs to change? London, 2018.
- Gentleman A, Zeldin-O’Neill S. Uncovering Windrush: ‘Only after months of reporting did the government apologise’ The Guardian 2018 10/11/2018.
- Abubakar I, Aldridge RW, Devakumar D, et al. The UCL–Lancet Commission on Migration and Health: the health of a world on the move. The Lancet 2018;392(10164):2606-54 doi: https://doi.org/10.1016/S0140-6736(18)32114-7[published Online First: Epub Date]|.
- Bozorgmehr K, Razum O. Effect of restricting access to health care on health expenditures among asylum-seekers and refugees: A quasi-experimental study in Germany, 1994–2013. PLoS ONE 2015;10(7):e0131483 doi: 10.1371/journal.pone.0131483[published Online First: Epub Date]|.
- Pike H. Doctors’ leaders join MPs to demand transparency in migrant health policies. BMJ 2019;365:l1527 doi: 10.1136/bmj.l1527[published Online First: Epub Date]|.
- Academy of Medical Royal Colleges. NHS charges to overseas visitors regulations, A statement from the Academy of Medical Royal Colleges. 2019 14/3/2019. https://www.aomrc.org.uk/wp-content/uploads/2019/03/2019-03-14_NHS_charges_overseas_visitors_regulations.pdf.
- NHS Inform. Healthcare for asylum seekers and refugees in Scotland: NHS Scotland, 2018.
- The HEAR Study. The health experiences of asylum seekers and refugees in Wales. Swansea: Swansea University, 2019
- Juárez SP, Honkaniemi H, Dunlavy AC, et al. Effects of non-health-targeted policies on migrant health: a systematic review and meta-analysis. The Lancet Global Health 2019;7(4):e420-e35 doi: 10.1016/S2214-109X(18)30560-6[published Online First: Epub Date]|.