Select Committee on Health Written Evidence


Memorandum by Dr Paul Williams (HA 24)


  1.  I am a principal in General Practice in Stockton-on-Tees in North East England. All of the 600 patients in my Primary Medical Services (PMS) practice are seeking asylum, have been given refugee status (or other forms of protection) or are failed asylum seekers. I have been the general practitioner to more than 1,000 people seeking asylum since my practice opened in April 2002.

  2.  I have taken testimony, as an independent medical expert, from more than two hundred people seeking asylum regarding physical and psychological health problems resulting from injury, imprisonment, rape and torture. I have received training and appraisal from the Medical Foundation for the Care of Victims of Torture.

  3.  I am a member of the Royal College of General Practitioners and have diplomas in tropical medicine, child health, family planning and obstetrics and gynaecology. I have a Masters degree in Public Health from the University of Newcastle upon Tyne.

  4.  I am an Honorary Lecturer in the school for health at the University of Durham.


  5.  There is a perceived problem of "health tourists"; people whose primary purpose in coming to the UK is to make free use of the NHS. Asylum seekers, by definition, are seeking protection in the UK from persecution in their countries of origin; their motivation in coming to the UK has never been proved to be linked to accessing NHS health care. If people were coming to this country and using the asylum process as a way of accessing free health care, I and other GP colleagues working in asylum health would be the main people noticing this phenomenon.

  6.  Of the one thousand people seeking asylum that I have provided primary care to in the last two years, I have only seen one case where I suspect "health tourism" was a factor in the decision to come to the UK. The family, from Iran, had a daughter with kidney disease. They suspected that she was getting inferior care in Iran, and had been in conflict with the authorities over their daughter's medical care. This conflict had resulted in the detention of the father prior to their decision to leave the country. I have seen no other cases where the decision to leave the country of origin, or the decision to come to the UK, has been influenced by the availability of health care in the UK. When I meet with colleagues who work in asylum and refugee health none of them talk about "health tourism" being a problem.

  7.  The existing and proposed changes to entitlement legislation will probably be successful in reducing health tourism, but would also have the damaging effect of denying necessary health care to many thousands of failed asylum seekers and other adults and children whose primary purpose in coming to the UK was to seek asylum not to get free NHS care.


  8.  The Home Office is making it much more difficult for people who apply for asylum in the UK to be granted permission to stay. According to Home Office statistics, in 2002 10% of people coming to the UK were granted refugee status by the Home Office, and a further 24% were granted exceptional leave to remain. In the first nine months of 2004, of the 37,575 people who claimed asylum only 1,195 (3%) were granted refugee status and 2,940 (8%) were given other forms of protection.

  9.  The proportion of successful appeals to the Immigration Appellant Authority (IAA) fell slightly from 22% in 2002 to 20% in the first nine months of 2004.

  10.  Home Office Research Study 243 examined the decision-making of asylum seekers by interviewing 65 asylum seekers. It found that most people were fleeing violence, persecution or threats of violence. These asylum seekers had very little knowledge of entitlement to benefits in the UK.

  11.  Most people who come to the UK to seek asylum will become "failed asylum seekers". Failed asylum seekers are not "bogus" asylum seekers. The burden of proof in an asylum application lies with the applicant to show that there is a reasonable degree of likelihood that they would suffer persecution (on the grounds of race, religion, nationality, political opinion or membership of a social group) if returned to their country of origin.

  12.  Many barriers to access to health care for people seeking asylum exist. These include difficulty in communicating in English, a poor understanding of the health care system in the UK, prejudice and racism towards asylum seekers from health service staff and fears about confidentiality and the possible cost of treatment. The existing and proposed changes will only increase barriers to access for those entitled to treatment, do nothing to support the inequality policy agenda and will result in large numbers of people living in the UK who do not get access to healthcare.

  13.  Access to all types of health care begins in primary care. The antenatal care provided in the UK ensures that maternal and perinatal mortality rates are low, vertical transmission of HIV reduces from more than 30% to less than 1% and babies are born in a safe environment. Denying access to care will only result in more vertical transmission of HIV, higher maternal mortality rates and higher perinatal mortality.


  14.  A cohort of 288 adults seeking asylum, who had been "dispersed" to Stockton-on-Tees in 2003, were followed for six months. 47% of people were from Africa, 40% from Asia and 6% were from Europe.

  15.  43% of adults presented with mental health problems after dispersal. The prevalence of Post Traumatic Stress Disorder was 7%, Depression 15% and Anxiety 3%.

  16.  Altogether the prevalence of HIV was 4%. All of the people with HIV were born in Africa, so the prevalence of HIV in Africans was 8%. On arrival at the practice only 25% of African adults knew their HIV status, and after six months of health promotion and encouragement of HIV testing 51% knew their HIV status. This still left 49% of African adults who did not know their HIV status. The prevalence of HIV in African adults who had ever had an HIV test was 16%. The audit concluded that there was likely to be undiagnosed HIV in African patients.

  17.  I have asked all of my patients with HIV, in clinical consultations, if they knew that they had HIV when they were in Africa. All of them were diagnosed in the UK. All of them have said that they did not know that they had HIV until they were tested in the UK. I have no way of knowing how truthful these responses were, but I have been given no reason ever to suspect that any of my patients with HIV had come to the UK to seek treatment.

  18.  46% of people with HIV disclosed rape or sexual assault during the six months of the study. The overall prevalence of rape or sexual assault was 17% in African people (43% in African women). People with HIV were significantly more likely to have disclosed rape than people without HIV.

  19.  There are significant barriers to HIV testing in African people. People are afraid of a positive result as they associate HIV with death from their own experiences in Africa. They have difficulty in building up trusting relationships with health professionals, fear that their HIV status will be disclosed to the Home Office and this will affect their asylum claims, and fear the huge stigma that a positive diagnosis brings in African communities. None of my patients with HIV are openly positive—I asked for a volunteer recently to speak at a community event about HIV that I had organized. Everyone was too afraid of persecution to let others know their status, and we had to get a speaker with HIV to come up from London. More work needs to be done to break down barriers to accessing voluntary counseling and testing services in the community, and to attempt to dismantle the prejudice and stigma surrounding HIV that exists in African communities.

  20.  If I thought that any of my patients who were diagnosed with HIV would be denied treatment if their asylum claims failed, I would have to tell them this when counseling them for HIV testing. At the moment, I can counsel them that "it is better to know" if they have HIV, because of the potential benefits to them of accessing treatment if they have the disease. If they might not be able to get free treatment, the benefit to the individual of knowing their HIV status would be minimal.


  21.  The proposals allow general practitioners to give "immediately necessary" treatment to failed asylum seekers. The notion of health problems falling neatly into those that are "immediately necessary"' and those that are not is a false one. Many non-urgent problems may, if not managed correctly, result in serious illness. For example, steroid inhalers are not "immediately necessary" for someone with asthma, but without them an individual may become dangerously unwell. The correct management of a pregnant woman with HIV reduces the risk of transmission from mother to child from 30% to less than 1%. The phrase "immediately necessary" was coined by general practitioners as a way of getting payment for seeing a patient registered elsewhere, not as a way of deciding which healthcare was essential and which was not.

  22.  It is difficult to tell when an asylum claim has "failed", as some cases may be subject to appeal or to judicial review. NHS staff have already reported people who are not failed asylum seekers being refused NHS treatment. Members of ethnic minorities or people seeking asylum (who are entitled to free NHS care) will be disproportionately affected.

  23.  The proposals will lead to confusion and prejudice amongst health service staff, undermining other important initiatives to improve social cohesion, redress inequality and facilitate access to health care for disadvantaged groups.

  24.  Doctors and nurses have an ethical duty to provide care for their patients, based on assessments of medical need and no other criteria. They are not trained, or professionally inclined, to deny treatment to those in need of it. These proposals conflict with ethical codes of conduct governing health professionals, including the GMC's "duties of a doctor".

  25.  It is only possible to determine whether or not someone has an "immediately necessary or life-threatening" problem or an infectious disease (categories that would be entitled to free treatment under the new legislation) by performing a medical assessment. Reception staff are unqualified and do not have the skills to make this determination, but are most likely to be the people turning away patients.

  26.  It is economically nonsensical to deny simple illness prevention, but allow expensive emergency care when a condition becomes life-threatening. Preventative medicine and early identification and treatment of illness reduces suffering and comes at a lower financial cost.

  27.  Asylum seekers move from lawful residency to an "illegal" status if they fail to secure the right to refuge. Withdrawal of health care eligibility for such a vulnerable group without enforcing their leaving the UK demonstrates a failure to take responsibility.

Case study 1 (KH has given his full consent for the disclosure of this information)

  28.  KH is a 36 year old former policeman from Zimbabwe. As the chief of his police station he took a stand against juniors who were facilitating farm occupations by "war veterans". His superiors heard about this, and put verbal pressure on him. K fled Zimbabwe after his family home was burnt down by Zanu-PF supporters in reprisal. He was diagnosed with HIV several months after arrival in the UK. He has been married for 14 years, but did have one extra-marital affair about six years ago, from which he thinks he caught HIV. He had no idea of his HIV status prior to his arrival in the UK. His lowest CD4 count was 47 and he is currently on antiretroviral treatment, provided free of charge by a local hospital. He is now a failed asylum seeker. He was not able to convince the Home Office or the IAA that there was "a reasonable degree of likelihood" that he would suffer persecution if returned to Zimbabwe as there was no evidence that he could put forward to substantiate his story, and the burden of proof in an asylum case lies with the applicant. He is terrified of returning to Zimbabwe, not because of the lack of HIV treatment (he says he would work to pay for treatment) but because he still reads about attacks by Zanu-PF supporters on people like him. As a failed asylum seeker he is not allowed to work (but he does earn a bit of money by doing work on friends cars), gets no benefits and has no housing provision (he lives on the floor of a friends house).

Case study 2 (KD has given his full consent for the disclosure of this information)

  29.  KD is the son of a doctor from West Africa. He is well-educated and articulate. Some time after his asylum claim failed he disclosed to me that he has been detained by the authorities in his country in 1999. During this time he was raped anally and a lime was inserted into his rectum. He says that he had never disclosed this to anyone before as he was too ashamed. "Late disclosure" of rape or torture is a common phenomenon described by the Medical Foundation for the Care of Victims of Torture. There are no legal avenues still open to him. After this disclosure we decided that an HIV test was sensible, and he was found to be positive. In fact his CD4 count was less than 50 and soon afterwards he was diagnosed with TB pericarditis and underwent heart surgery. Under the new entitlement arrangements for failed asylum seekers he would have been entitled to the urgent heart surgery and treatment for TB (but would have been presented with a bill for it afterwards), but would not have received antiretroviral treatment. By now he would be dead. Fortunately the local hospital is not aware of his "failed" status and is giving him free treatment. K is terrified of returning to his country, and is currently living in a house funded by donations from a church group.

Case study 3 (SO has given her full consent for the disclosure of this information)

  30.  SO is from Uganda. She was abducted from her home and kept in a cage by a rebel group. During this time she was multiply raped vaginally and anally. Her asylum claim failed after the medical evidence provided by me was rejected as being "inconclusive". It is very unusual for anyone to have "conclusive" medical evidence months after being raped. A further submission by her solicitor and by me explaining this was rejected by the IAT. She has children in her country being looked after by a relative, but is terrified to return. She was diagnosed with HIV in Dover and began antiretroviral treatment last year when her CD4 count was 144 and she developed TB. At the time she was gaunt and depressed. Now she is lively, well and is an active member of her church group. This church provides her with accommodation. Without antiretroviral treatment it is likely that she would now be dead.


  31.  Before framing new legislation, an evidence-based impact assessment of both the new proposals for primary care and those recently introduced for hospital care should be performed. This should include consideration of the likely impact on personal and public health and an economic analysis of the status quo and of proposed changes. HIV and AIDS should not be considered separately from other illnesses or health problems that affect this group.

  32.  Any link between immigration status and health care entitlement should be removed. Free primary and secondary medical care should continue to be provided until someone is removed from the UK.

  33.  If the proposals are enacted, everyone should be entitled to a free health assessment by a health professional in order to establish their degree of need. When establishing entitlement to free care, the means to pay should be taken into account. The consequences of denying free NHS care to a wealthy Texan are very different from denying care to an HIV positive Zimbabwean.

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