The importance of universal access to healthcare could not be clearer than during a global pandemic—the health of any individual impacts the health of the whole population
Universal and equitable access to healthcare for migrants is essential for a healthy society. [1] Yet, over the past decade in the UK, universal health coverage (UHC) has been undermined. [2] The introduction of charging regulations, the “NHS visitor and migrant cost recovery programme”, requires upfront payment, at 150% of NHS tariffs, from those unable to prove their entitlement to healthcare. [3] Exemptions in the guidance exist, for example for the treatment of certain infectious diseases, but these are insufficient and ineffective. Experience of treating migrants with tuberculosis (TB) shows these are ineffective, with research worryingly demonstrating a “significant delay” in TB treatment among non-UK born patients since the charging regulations were introduced. [4] The regulations leave healthcare professionals in an impossible position. Rather than following the NHS founding principles of treating all people equally, regardless of ability to pay, healthcare teams are forced to deny care to people in vulnerable positions in our society, with consequences for all.
The evidence of a delay in, or withdrawal of, essential treatment is of particular concern in the current climate. The novel coronavirus (covid-19) was added to the list of exempt conditions on 29 January 2020, but treatment becomes chargeable if the test result is negative. [1] In practice, this is completely unworkable, and is causing harm to individuals and the public more widely. For a patient to seek healthcare for possible covid-19 would require them first, to be aware of the exemption, second, be free from fear of accessing healthcare (a reason given for not seeking healthcare in the Doctors of the World UK clinic, where people seen have on average been in the UK 5.5 years before trying to access healthcare), and third, be able to pay for any resulting treatment if the test were negative. [5] In addition, the false negative rate of the test renders this exemption medically flawed at both an individual and public health level. [6] Furthermore, the charging regulations do not include any routine exemption of children. According to the Royal College of Paediatrics and Child Health, in the emerging paediatric multisystem inflammatory syndrome associated with covid-19 “SARS-CoV-2 PCR testing may be positive or negative.” [7] Put plainly, with the existing exemption, not all children with this serious and developing condition are entitled to free care.
The fear described in accessing healthcare is not only due to incurring unmanageable debts, but of arrest. [8] Although the previous data sharing agreement between NHS digital and the Home Office was suspended in May 2018, data sharing between immigration and health services persists. Those not entitled to free care are given a bill, with a warning that any debt of £500 or more at 2 months may result in their data being shared with the Home Office, and negatively impact future visa applications. [9] This fear has been found to result in delay in accessing healthcare, the negative impacts of which are amplified during an infectious disease outbreak. [8]
The increased risk of death observed in Black Asian and Minority Ethnic people from covid-19, which has also been shown starkly among healthcare workers, is extremely concerning. [10,11] While the causes are unknown, it is clear racism, xenophobia and discrimination contribute to poor health outcomes, not least in covid-19. [1] It is essential to remove any possible contributors to this disparity, and one immediate way would be to suspend the charging regulations, given the government’s equity analysis found: “non-white people…are on some occasions targets in the application of the 2011 regulations due to speculation or assumption that they are not resident in the UK.” [12]
Lancet Migration global collaboration has joined Members of Parliament (MPs), Royal Colleges, and many other organisations in calling for the immediate suspension of the NHS charging regulations. [13,14] It has also called for data sharing “firewalls ‘between immigration and healthcare’, and for the government to ‘actively counter racism, xenophobia and discrimination’”. [15,16] The move to end the immigration surcharge for NHS workers is welcome, but it does not go far enough. All those on a visa are contributing to the NHS in the same way British citizens are, through tax and national insurance, and everyone needs healthcare.
In suspending the NHS charging regulations, the government could demonstrate its focus is on public health not political point scoring, its support to all health and social care workers, its commitment to countering racism, xenophobia and discrimination, and its desire to avert a preventable resurgence in the pandemic that results from excluding any member of the population. [17]
Lucinda Hiam, Clinical Lead for UK Policy and Advocacy, Doctors of the World UK; Programme Officer, Lancet Migration; NHS GP
Parth Patel, Policy Officer, Lancet Migration; Junior doctor in the NHS
Miriam Orcutt, Executive Director, Lancet Migration; Senior Research Fellow, UCL Institute for Global Health
Anna Miller, UK Policy and Advocacy Manager, Doctors of the World UK
Maggie Rae, President of the Faculty of Public Health
Competing interests: None declared
References:
1] The UCL–Lancet Commission on Migration and Health: the health of a world on the move, Abubakar I et al., Lancet. 2018; 392: 2606-2654
2] https://www.bmj.com/content/367/bmj.l7054
3] https://www.gov.uk/government/collections/nhs-visitor-and-migrant-cost-recovery-programme accessed 19 May 2020
4] https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-08524-9#citeas accessed 19 May 2020
5] https://www.doctorsoftheworld.org.uk/wp-content/uploads/2018/11/DOTW_2019_lowress_alt.pdf
6] https://www.bmj.com/content/369/bmj.m1808 accessed 19 May 2020
7] https://www.rcpch.ac.uk/sites/default/files/2020-05/COVID-19-Paediatric-multisystem-%20inflammatory%20syndrome-20200501.pdf
8]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/793132/overseas-chargeable-patients-nhs-debt-and-immigration-rules.pdf
9] https://www.doctorsoftheworld.org.uk/wp-content/uploads/import-from-old-site/files/Research_brief_KCL_upfront_charging_research_2310.pdf
10] Black, Asian and Minority Ethnic groups in England are at increased risk of death from COVID-19: indirect standardisation of NHS mortality data, Aldridge R et al., Wellcome Open Research 2020 (pre-print)
11] https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article
12] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/735353/equality-analysis-charges-ovs-visitors-acc.pdf