House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

APPENDIX 25

Memorandum by Médecins du Monde UK (HA 32)

SUMMARY:

Médecins du Monde UK is very concerned that the recent and proposed changes to NHS entitlement (charges for overseas visitors) prevent, and will further prevent, vulnerable members of society from accessing healthcare. We are concerned about the consequences of this for individuals and for public health.

With particular reference to HIV/AIDS, there are some specific public health consequences of denying access to HIV treatment (or to primary care in general) for sections of the population:

— A lack of access to treatment will reduce the take up of voluntary HIV testing, thereby increasing the proportion of HIV cases going undiagnosed;

— Primary care plays an important role in early detection of HIV and is, therefore, essential to help people get treatment and to prevent the spread of the epidemic;

— Provision of treatment to prevent a person's condition worsening also has direct implications for how infectious that person is and, thus, for the spread of the epidemic;

— Individuals who are subject to charges for HIV treatment (or other healthcare) are less likely to complete other courses of treatment to which everyone is entitled free of charge (eg TB or sexually transmitted infections);

— Exclusion and stigmatisation of groups at high risk of HIV infection will not help to reduce the spread of the disease.

The new and proposed regulations undermine effective access to healthcare services, including HIV/AIDS services:

— Only providing "immediately necessary treatment" is not cost effective and will ironically create a system that refuses preventive and curative treatment, but offers treatment when the patient is dying;

— The regulations are not understood clearly by health professionals and NHS service users who are both confused about the conditions to entitlement. This increased confusion creates further barriers to healthcare for socially excluded groups and migrants;

— The new and proposed regulations undermine social cohesion and encourage discrimination;

— The new and proposed regulations are in clear contradiction with government policies on HIV/AIDS, public health and improvement of NHS services;

— The UK Government needs to look into other European countries which safeguard access to healthcare for all.

Other issues:

— The new and proposed regulations conflict with health professionals' duty to care and require the NHS to act as an immigration body;

— The new and proposed regulations do not acknowledge the need to ensure effective access to healthcare for children and pregnant women.

Médecins du Monde recommends that:

— the Government does not go ahead with the proposed changes to entitlement to primary care;

— an impact assessment to investigate the impact of the recent and proposed changes on individuals, public health and the NHS is carried out;

— the Government re-examine the rules concerning charges for secondary care which were introduced in April 2004 and take action to ensure that vulnerable members of society have access to hospital treatment;

— people living with HIV in the UK have access to treatment and care;

— clear information about access to NHS care is required for both patients and health professionals;

— special attention is paid to the health needs of particularly vulnerable groups such as children and pregnant women to ensure that they have access to healthcare;

— the vitally important role that access to primary care plays in protecting public health is recognised.

INTRODUCTION:

1. Médecins du Monde is a medical humanitarian non-governmental organisation which provides healthcare for the most vulnerable populations suffering from crisis and exclusion in both developed and developing countries. As well as providing healthcare, we "bear witness" to human rights abuses, particularly obstacles to healthcare, and advocate for access to healthcare.

2. Médecins du Monde has over 20 years of experience in providing medical assistance and in advocating for better access to healthcare. Médecins du Monde UK recently assessed needs in East London and is presently launching a health project working with vulnerable groups which will, among other things, document barriers to healthcare.

3. Through our extended experience in providing and documenting access to healthcare in other countries, at a European and a world-wide level, we are extremely concerned about recent and proposed changes to NHS entitlement. As we are already witnessing the impact of similar restrictions to access healthcare in other European countries, we have strong reasons to believe that these changes already impair (and will impair more dramatically in the future) access to healthcare for vulnerable populations as well as access to HIV/AIDS services.

4. As a medical humanitarian organisation, we are concerned that the present and proposed policies initially designed to regulate charging for "overseas visitors" have inadvertent consequences on individual and public health and will prevent vulnerable members of UK society from having effective access to healthcare.

5. For this reason we have urged the Government not to introduce NHS charges at the primary care level and to repeal the changes introduced in April 2004. We have also joined with other medical and refugee organisations to call on the Government not to implement these changes without carrying out a prior in-depth impact assessment. This process should assess the potential impact on the individual, on health services and front-line staff, the voluntary sector and on public health.

Consequences of the new and proposed changes in charges for overseas patients with regards to access to HIV/AIDS

6. Protecting access to healthcare for vulnerable groups—The new and proposed changes to NHS entitlement endanger the core principle of the NHS which is to ensure that "`healthcare should be free, available to all and of uniform quality no matter where people live and whatever their background." To make access to healthcare subject to the ability to pay for treatment is against the basic principle of the NHS, which is to provide access to healthcare to everyone regardless of their resources.

7. Although this principle is now 50 years old, it was emphasised in the Queen's Speech only last month: "My Government will continue its reform of the National Health Service, offering more information, power and choice to patients, with equal access for all and free at the point of delivery."

8. Violation of international law—The new and proposed regulations will be in clear violation of the right to the highest attainable standard of health (article 12 ICESR) as interpreted by the UN Committee on Economic Social and Cultural Rights which monitors States' observations of the International Covenant on Economic Social and Cultural Rights ratified by the UK in 1976. The General Comment 14 clearly sets out how the right to health should be respected in practice in paragraph 34. "In particular, States are under the obligation to respect the right to health by, inter alia, refraining from denying or limiting equal access for all persons, including prisoners or detainees, minorities, asylum seekers and illegal immigrants, to preventive, curative and palliative health services; abstaining from enforcing discriminatory practices as a State policy; and abstaining from imposing discriminatory practices relating to women's health status and needs."

9. ECHR article 3—The new and proposed regulations will potentially create situations in violation of article 3 of the European Charter of Human Rights. Denying access to healthcare for some people can worsen their medical conditions to a stage where it becomes inhuman and threatening for their life.

10. Limited evidence—It is difficult to provide evidence in the form of detailed case studies and statistics at this stage. Firstly, the changes introduced in April 2004 are still poorly understood within the health services and their impact is still trickling through the NHS. Secondly, the changes to primary care are still proposals. Nonetheless, it is clear that both the recent and proposed changes are contradictory to many other areas of government policy and that there are serious grounds for concern about their potential impact on the health of vulnerable people, on public health and on social cohesion.

11. The importance of early detection—People infected with HIV are often diagnosed long after being infected. Restricting access to healthcare services, especially primary care services, will reduce the number of diagnosed people and will increase their medical vulnerability. Early detection of HIV/AIDS is important for several reasons—so that an infected individual can have treatment to prevent their condition worsening, so that they can take action to prevent transmission to others and also so that they can alter their lifestyle to minimise the risks of deterioration in their health.

12. The Chief Medical Officer emphasised the importance of early detection of HIV as a key element in controlling the spread of HIV infection in his Annual Report on Public Health in England in 2003[25] where he noted that "a relatively large proportion of people are being diagnosed late in the course of their HIV disease, leading to avoidable illness and death and creating opportunities for the disease to spread more widely within the population."

13. Discouraging HIV testing—Linked to this issue of early detection is the impact that a lack of access to treatment will have on uptake of HIV testing. We know from experience in developing countries that availability and affordability of HIV treatment increases uptake of testing and consequently awareness and preventive action against the spreading of HIV. An estimated 33% of people with HIV infection in England remain undiagnosed.[26]

14. Provision of voluntary HIV testing and counselling is to remain freely available to everyone. This policy is vital to encourage people to take an HIV test and seek advice to prevent transmission of the disease. This policy will be seriously undermined, however, if people know they will not be able to get free treatment after that. According to HIV/AIDS organisations, people within communities of high prevalence for HIV have begun to ask why they should bother to test for HIV if they cannot obtain treatment for it. Restricting access to NHS entitlement will only undermine education campaigns and other measures to raise awareness among these communities.

15. Access to treatment—Over and above its consequences for an individual's health, access to treatment for HIV infected people is also a public health issue. HIV treatment prevents a person's conditions worsening and as the condition worsens they become more infectious. Excluding a part of the population living in the UK to access such treatment, therefore, reduces the chance of tackling efficiently the spread of HIV within the UK. The number of new cases of HIV infection has more than doubled since 1998[27] and HIV infection is now the fastest growing serious health condition in England.[28] This approach is in stark contrast to the Department for International Development's policy to tackle HIV/AIDS in the developing world whereby "the UK supports efforts to provide increased, and eventually universal, access to treatment and care for people with HIV and AIDS".

16. Undermining control of communicable diseases—The new and proposed regulations undermine measures tackling communicable diseases such as (non-HIV) sexually transmitted infections (STIs) and TB, which are deliberately exempt from charges. However, how can people infected by these conditions effectively access free treatment if they cannot be diagnosed in the first place? Within the framework set out by the new and proposed changes, these medical conditions can only be assessed at a later stage in A&E department. Furthermore, it seems difficult to believe that people in need of treatments which are exempt from charges will know that they are entitled to these treatments, free of charge, when the regulations themselves are very poorly understood among NHS staff.

17. This lack of effective detection will increase risks of communicable disease transmission which are already worrying. As figures from the British Thoracic Society (BTS)[29] and TB Action Plan[30] from the Chief Medical Officer show there is a rise among the number of TB cases in the UK and, as the last Health Select Committee report on sexual health[31] highlighted, there are poor results for tackling STIs within the NHS, where diagnoses of new infections have increased.

18. Incompletion of TB treatment—People receiving treatment for tuberculosis (TB) are likely to be discouraged from completing their treatment if they are faced with a bill for other medical treatments which are not free of charge. Under the regulations for secondary care already in force, people co-infected with TB and HIV have been reported to stop their treatment halfway through when asked to pay for their HIV treatment. This has serious consequences for their health since incomplete treatment fails to cure the disease. It also has serious consequences for public health because lapsed treatment also contributes to the promotion of drug resistant TB which is more difficult and expensive to treat.

19. Access to primary care—It will be unhelpful and contradictory for some services to be free within specialist and often hard-to-access NHS units and not within primary care. Research shows that some groups, including African or Caribbean communities, prefer to use general practitioner services than specialist genito-urinary provision. If some people are denied initial examination and health checks at primary care level, or discouraged by their cost, it is highly likely that prevalence of sexually transmitted infections and other diseases will continue to rise.

20. In his 2003 report on public health, the CMO noted some weaknesses in the provision of HIV/AIDS testing in genito-urinary medicine settings and recommended that "urgent consideration should be given to ways of expanding non-genito-urinary medicine clinic-based HIV testing services in primary care and community settings." The proposals to restrict access to primary care for some groups of the population are in direct contradiction to this policy.

21. Groups at high risk of infection—The new and proposed regulations do not acknowledge the fact that according to many public health reports some groups of migrants are at particularly high risk of HIV infection. It is particularly inappropriate, therefore, to enact restrictions to access healthcare which will mainly affect the migrant population. We already know that HIV infected Africans, for example, are unequally accessing HIV/AIDS services and that TB is the most common co-infection among African adults infected with HIV.[32]

22. Stigmatisation—The new and proposed regulations will undermine positive measures to integrate HIV infected people within UK society and will further exclude the migrant population from prevention campaigns and HIV testing. It is very important to effectively detect HIV infected people through testing by targeting groups most at risk of infection through prevention campaigns without stigmatising those groups. The restrictions to healthcare entitlement do not encourage positive integration of the migrant population within mainstream healthcare services, do not encourage those groups to undertake a HIV test and do not help them to be aware of their entitlement to free testing and counselling.

23. Restricting access to healthcare services in general will undermine effective ways of testing HIV, such as routine testing during antenatal care. This policy has been relatively successful in the UK, and HIV diagnosis rates in pregnant women have improved since the late 1990s. However, 25% of cases among pregnant women still go undiagnosed in London meaning that babies are still being born infected with HIV.[33] Any measures which reduce access to antenatal care or primary care will only further undermine this policy.

24. Defining "immediately necessary treatment"—According to the changes, "immediately necessary treatment" will still be available free on the NHS. This concept, however, is not clearly defined and does not give clear guidelines as to how it can be implemented effectively. If someone is denied access to a primary care consultation and assessment, how will health professionals be able to determine whether treatment is immediately necessary? Any medical condition is potentially urgent if not treated and detected quickly enough.

25. The regulations also contain contradictions about how, in practice, will the concept of free "immediately necessary treatment" be implemented. Health professionals will not be the first person to see the patient. General practice and hospital staff at the reception will be left with the responsibility for assessing patient's eligibility for medical care. Such implementation of the rules leave the door open to mistakes where patients in need of "immediately necessary treatment" will be turned down on eligibility grounds. It has been reported to us that a pregnant women was refused healthcare by a hospital manager without seeing a health professional although she was bleeding and 7 months pregnant.

26. Cost effectiveness—There is no evidence that the recent and proposed changes will bring any cost savings to the NHS. In relation to HIV, for example, one week's stay in intensive care is reported to cost almost as much as an annual combination therapy which is now under £10,000. Refusing HIV treatment and accepting to treat the patient in A&E services until her/his medical condition has deteriorated is thus unlikely to result in any cost saving.

27. Increased confusion—Médecins du Monde UK does not believe that strengthening rules on access to healthcare bring more clarity to the situation. More checks on entitlement actually create more confusion among NHS staff and among the general public. This, in turn, creates further barriers for vulnerable groups in the UK which will prevent their access to healthcare and will not improve their health.

28. Me«decins du Monde UK believes that there is an urgent need to inform people of their right to healthcare. Even before amendments to secondary care come into force, (1 April 2004) there was evidence of confusion among NHS staff and among beneficiaries about entitlement to healthcare. The new and proposed changes to entitlement are only likely to increase this confusion and to see health services turn away more people who remain legally entitled to free NHS treatment or to make people wrongly believe that they are not entitled.

29. For example, we have already seen apparent contradictions between the text of the regulations amended in April 2004 and the guidelines on implementation of these regulations. According to recent NHS guidelines on asylum seekers' entitlement, it is said that "if the claim is finally rejected (including appeals) before the patient has been in the UK for 12 months, they become chargeable for all treatment (including an existing course of treatment) from the date of rejection of the claim, as has always been the case, and they do not become exempt from charges after 12 months' residence here."[34] But such implementation does not comply with the amended text of law, which clearly states that no course of treatment should be stopped on entitlement grounds: "where it is established that a person does not meet the residence qualification in paragraph (1)(b) and that person has already received services as part of a course of treatment on the basis that no charge would be made, no charges may be for the remainder of that course of treatment." The regulations imply that a person would not be charged for an ongoing course of treatment if their status changed, while the implementation guidance affirms that they will be charged.

30. Another example of confusion which already exists concerns the rules on access to healthcare for students. We witnessed the case of a Turkish student who was wrongly denied access by her GP on the basis that she had not completed six months residency yet. She ended up in the walk-in centre where the nurse confirmed that she could not register with a GP but agreed to give her some care at the walk-in centre. However, amendment to regulation 4(1)(c)(iii) clearly specifies that an overseas visitor is exempted from charges when "pursuing a full time course of study which is substantially funded by the United Kingdom or is at least six months duration".[35] She is still not registered with a GP although she is entitled to NHS care. This case clearly shows that there is worrying confusion about the rules around NHS entitlement which will result in people being wrongly refused access to healthcare services or people who will wrongly believe that they are not entitled.

31. It has been reported to us the case of a dentist informing an asylum seeker that she was not entitled to NHS hospital treatment as she was an asylum seeker. Interpretation of the new regulations to hospital treatment are clearly misunderstood in that case as an asylum seeker is believed not to be entitled.

32. HIV organisations have already noticed difference of interpretations from one hospital to another which makes their work particularly difficult in terms of referral as poor knowledge of exact conditions of entitlement wrongly delay necessary treatments.

33. Need for accurate terminology—Although the new and proposed regulations are designed to target "overseas visitors", Médecins du Monde UK is concerned that people living in the UK will be inadvertently affected. The terminology used in the April 2004 Regulations and the summer 2004 consultation on primary care do not make it clear that these regulations will directly affect vulnerable families, children and individuals residing in the UK.

34. Social exclusion—In practice, people living on the edge are already marginalised within the healthcare system. For these stigmatised groups, asking for more documentary evidence is likely to make it even harder for them to register with NHS services even though they are, and will remain, entitled to such services. Médecins du Monde UK opposes tougher regulations on eligibility that could create further barriers to healthcare for stigmatised social groups (migrants, Roma community, homeless people, drug users, sex workers, people with mental health problems, elderly people).

35. Social cohesion—The general public regularly receives misleading and manipulative messages about migrant populations and ethnic minorities. Any emphasis on proof of legal status is likely to encourage discrimination against those groups (refugees, asylum seekers, Black and Ethnic minorities, people from new EU member states, legal migrant workers) and will, therefore, impair their access to healthcare. It will also encourage discrimination based on appearance. People may be prevented from accessing healthcare because of their skin colour or their ability to speak English.

36. Evidence of entitlement may be requested disproportionately from non-white people. Public authorities are required under the Race Relations (Amendment) Act 2000 to eliminate unlawful racial discrimination, promote equality of opportunity and promote good relations between people of different racial groups and assess new policies for their likely impact on race equality. There is an urgent need for the Government to carry out a racial equality impact assessment.

37. Contradictory policies within the Government—The new and proposed changes are directly contradictory to other areas of government policy, undermining the aim of joined up government. The effects of these changes to NHS entitlement will work against, or in contradiction to, the following areas of government policy and strategy:

— Similarly, refusing to treat people before they become emergency cases will consequently put more strain on A&E services which are already stretched to the limits. Such a workload within the A&E services may impact on the quality of care and the waiting time that is already very lengthy. It will consequently go against the Government's recent efforts to reduce pressure on A&E services.

38. Learning lessons from other European countries—Médecins du Monde, through its European network, is already witnessing the impact of similar restrictions on access to healthcare in other European countries. Similarly, we are aware of positive examples from other countries where access to healthcare is not restricted or where safety nets have been established to try and ensure that vulnerable people are able to access healthcare when they need it. Médecins du Monde welcomes moves to ensure that a person's health and the health professional's duty to care are rightly acknowledged. In Italy, for example, the law asks health professionals not to denounce undocumented migrants and not to reveal their identity to the authorities in order for them to fully enjoy healthcare services without fear of being arrested or deported. In Spain, everybody living in the country is entitled to healthcare regardless of their legal status.

OTHER ISSUES

39. Separation of health services from the immigration system—Restricting the duty to care will undermine the role of health professionals. It will create a particular conflict for health professionals, who will be torn between compliance with the law and compliance with their duty to care and patient confidentiality.

40. People in need of healthcare are already, and will be increasingly, deterred from going to healthcare services in fear of being denounced to the immigration services. Recently, we heard of a man hit by a car who refused to go to A&E services for fear of being arrested. We also heard of immigration officers coming to maternity units in hospitals to interview women who had recently given birth. Médecins du Monde UK considers that healthcare needs to be kept separate from immigration rules.

41. Children—Neither the recent or proposed changes mention children. It remains unclear what children are entitled to, in the case where their parents are not eligible to NHS care. Médecins du Monde UK is extremely concerned about the impact of these changes on children. Any measures which discourage HIV testing among pregnant women or which deny mothers-to-be access to HIV treatment, will result in more babies born infected with HIV. We find it unacceptable that this, preventable, situation should occur in Britain today.

42. Infant immunisation—If children have no access to healthcare services because of their parents' status, how will they have access to immunisation and be able to complete it successfully? Immunisation is essential to give children the best chance of developing immunity against infectious diseases in a safe and effective way and minimises their risk of catching the diseases. Ignoring the importance of infant immunisation and not providing access to healthcare for children whose parents are not entitled is very likely to increase the number of children at risk of catching to a disease and to trigger outbreaks of the disease. It is also important to stick to the immunisation schedule, as a delay can leave a baby unprotected and can increase the chances of adverse reactions to some vaccines, such as pertussis (whooping cough).

43. Pregnant women—Neither the new or proposed regulations mention the situation of pregnant women. Denying access to antenatal and postnatal care to pregnant women on eligibility grounds will endanger the mother and baby's lives. It will increase risks of maternal and foetal complications and death, especially for vulnerable women who are already 20 times more at risk of maternal death.[40]

44. Médecins du Monde UK believes that the situation of pregnant women is seriously neglected within the framework of the new and proposed regulations as has been witnessed by refugee and medical organisations. We know of two cases of pregnant women who had been refused antenatal care by the Hospital Manager without seeing a midwife or a doctor. One was a failed asylum seeker and was refused antenatal care. Another one (case quoted earlier on) was also a failed asylum seeker but was in need of "immediately necessary treatment" as she had pre-term bleeding and seven months pregnant. She was not seen by a clinician and was denied antenatal care unless she would sign an undertaking to pay for it. What is more, the Hospital Manager reported the client's whereabouts to the Home Office. In each case, the midwives were oblivious of the fact that pregnant women were turned away and were very surprised to find out when the women turned up for birth had previously been refused antenatal care.

45. From our experience in other European countries, Médecins du Monde UK believes that pregnant women should not be excluded from access to healthcare services. In Germany, for example, pregnant women have only got two options to give birth safely. First, they can choose to give birth anonymously in some cities but will have to give up their baby to adoption services. Alternatively, they can get pre and postnatal care, the necessary vaccinations and medical tests provided that they inform the German Home Office of their presence in the country. This option implies that women will be threatened of being deported after giving birth. Both options put pregnant women particularly at risk and endanger both the woman and baby's lives, as the woman will look for alternative ways to give birth in order not to give up her baby or to avoid to be deported with her child. Furthermore, babies born in Germany to undocumented parents are also denied any necessary medical care because they do not have an official birth certificate.

RECOMMENDATIONS

46. Médecins du Monde UK urges the Government not to go ahead with its proposed restrictions in access to primary healthcare, and instead to ensure that vulnerable members of society have effective access to healthcare. People in need of primary healthcare should not be excluded from it on the grounds of immigration status.

47. We call on the Government to investigate carefully what implications restricted access to free NHS primary care would bring for individuals, wider society and the NHS, before introducing any changes. This impact assessment should seek to measure the effects in terms of the impact on the individual, on health services and front-line staff, the voluntary sector, on particularly vulnerable groups, on public health and social exclusion. There should also be a race equality impact assessment as required under Race Relations Amendment Act 2000.

48. The Government should re-examine the rules concerning charges for secondary care that were introduced in April and should instead ensure that vulnerable members of society have access to secondary care.

49. In line with the above recommendations, we call on the Government to recognise the ethical, public health and economic arguments against denying access to HIV treatment. People living with HIV in the UK should have access to treatment and care.

50. Médecins du Monde UK calls on the Department of Health to clarify an already confusing situation relating to NHS entitlement. We consider that there is a serious need for clear information about NHS entitlement to be disseminated to the general public and to health professionals. This information should particularly address the needs of vulnerable groups.

51. We call on the Government to pay particular attention to the health needs of especially vulnerable groups, such as children and pregnant women, when considering any measure which will have an impact on their access to healthcare.

52. Médecins du Monde UK considers the link between primary care and public health is vital and urges the Government to recognise the vitally important role that universal access to primary care plays in protecting public health.

25 Chief Medical Officer for England (2003) Annual Report on Public Health in England. Back

26 idem Back

27 Health Protection Agency (HPA), HIV and other Sexually Transmitted Infections in the United Kingdom in 2003 Annual Report, November 2004. Back

28 Chief Medical Officer for England (2003) Annual Report on Public Health in England. Back

29 Fears over TB infection "hotspot", BBC News, 2004/08/03, http://news.bbc.co.uk/go/pr/fr/-/1/hi/england/london/3529032.stm Back

30 Stopping Tuberculosis in England. An Action Plan from the Chief Medical Officer, October 2004. Back

31 House of Commons, Health Committee, Sexual Health, Third report of session 2002-03, volume 1, 11 June 2003. Back

32 African HIV Policy Network, Annual Report 2003-04. Back

33 Chief Medical Officer for England (2003) Annual Report on Public Health in England. Back

34 Implementating the Overseas Visitors Hospital Charging Regulations. Guidance for NHS Trust Hospitals in England. Department of Health, April 2004, paragraph 6.23. Back

35 The National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2004, regulation 4(1)(c)(iii). Back

36 DFID, Taking action. The UK's strategy for tackling HIV and AIDS in the developing world, July 2004. Back