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
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
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
positiveI 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
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