Select Committee on Health Written Evidence


Memorandum by the Reaching Out Project, Medact (HI 27)

HEALTH INEQUALITIES

1.  ABOUT THE REACHING OUT PROJECT, MEDACT

  The Reaching Out Project, Medact aims to improve access to maternity care for marginalised women from Black and minority ethnic communities.

  Medact is a membership organisation of health professionals. Medact speaks out for countless people across the globe whose health, wellbeing and access to proper health care are severely compromised by the effects of war, poverty and environmental damage.

2.  BACKGROUND

  This submission focuses on maternal health of marginalised women from Black and minority ethnic communities.

  Maternal health outcomes for this group are significantly worse than for the White population. The recent report of the Confidential Enquiry into Maternal and Child Health found that Black African women have maternal mortality rates 5.6 times higher than White women; Black Caribbean 3.7 times higher; Middle Eastern 2.9 times higher; "Other" 2.5 times higher; Bangladeshi 2.1 times higher; Indian 1.9 times higher; and Chinese and other Asian 1.3 times higher (Lewis 2007a:30).

  Maternal mortality rates for refugees and asylum seekers are extremely high. In the period 2003-2005, 36 of the 295 maternal deaths in the UK were of refugees and asylum seekers (Lewis 2007a). The total number of refugee and asylum seekers births was not known, so a mortality rate could not be calculated. As a rough indication, 12% of maternal deaths in 2003-2005 were to refugee and asylum seeking women while the UN High Commission for Refugees estimates that refugees make up about 0.3% of the UK population.

  Infant mortality data does not yet permit a comprehensive analysis by ethnic background. The limited data which is available indicates significantly worse health outcomes to children born to Black and minority ethnic mothers. The infant mortality rate for children of mothers born in Pakistan was 10.2 per thousand live births in 2002-2004 and 8.3 per thousand live births where the mother was born in the Caribbean (Department of Health 2007). These are, respectively, 108% and 63% higher than the national average.

  Many births to marginalised women from Black and minority ethnic backgrounds will fall within the "NS-SEC Other" category. This group has an infant mortality rate of 9.3 per thousand live births which is 90% higher than the population as a whole (Department of Health 2007).

3.  TERM OF REFERENCE

1:   The extent to which the NHS can contribute to reducing health inequalities, given that many of the causes of inequalities relate to other policy areas eg. taxation, employment, housing, education and local government

3.1  Eligibility for free NHS maternity care

  Free NHS maternity care is available to women who are considered to be "ordinarily resident" in the UK or who fit within certain defined categories. Women who are not entitled to free NHS care will be charged for their care but care cannot be refused on grounds that a woman is unable to pay. Department of Health guidance states that this is because of the severe health risks associated with conditions such as eclampsia and pre-eclampsia (National Health Service 2004)

  One objective of the current regulations is to address "health tourism". A "health tourist" is a person who comes to the UK with the express purpose of making use of free NHS services. While there have been various statistics produced on the costs of overseas visitors to the NHS, these have not been disaggregated. In addition to any "health tourists" who obtain free NHS care, these figures include people who have travelled to the UK in order to receive care as private patients and have paid for this care, and those who are living in the UK but are liable to pay for care because of their immigration status.

  Amongst the women who are not entitled to free NHS maternity care are many vulnerable migrants, including asylum seekers whose appeals have been exhausted ("refused asylum seekers"), trafficked women and undocumented migrants. These women have not come to the UK in order to obtain health care and may have lived in the UK for some years before seeking treatment. Project London provides health services to undocumented migrants. In its first year of operation the average service user had been in the country for three years ((Project London 2007), indicating that service users had not come to the UK in order to seek health care.

  The financial circumstances of these women are often extremely difficult. They are not permitted to work or to obtain state benefits. A small number of women receive subsistence support from NASS. Many destitute women rely on support from church, community groups and friends. They do not have the funds to pay the charges for maternity care, which range from £1500 to in excess of £3000 for a normal vaginal delivery. Neither are these women in a position to negotiate repayment plans as their future may be very uncertain.

  The policy of charging for maternity care has the effect of deterring women from obtaining care. Many women are intimidated by the prospect of incurring a debt of several thousand pounds when they know it will be impossible to repay it. They therefore choose not to receive care they cannot afford, and disappear from maternity services (Joint Committee on Human Rights 2007, Kelley & Stevenson 2006). Some women are able to raise part of the sum but feel that they have no option but to discontinue the care when the money runs out. Some women are fearful that their irregular immigration status will be reported to the Home Office.

  Lack of compliance with the policy has also resulted in women being denied or deterred from obtaining care. The Joint Committee on Human Rights inquiry into the treatment of asylum seekers 2006-7 specifically considered the misapplication of the rules by hospitals and the deterrent effect of the rules. The Committee concluded:

    It is clear to us that there is considerable confusion. Pregnant women are denied, or fail to access, essential care as a result. The evidence shows that additional [Department of Health] guidance has not removed the confusion.

  The Reaching Out Project has found numerous instances of the policy not being applied.

    —  Women have been refused care when they have arrived at the hospital in labour.

    —  Women have been refused care unless they can pay. In some cases the refusal has been communicated aggressively.

    —  Voluntary organisations advocating for individual women have found it extremely difficult to resolve disputes about entitlement to care. Advocates state that they have quoted the regulations and guidance without effect and the response from the Overseas Visitor Managers has often been extremely unhelpful and, in some cases, very rude.

    —  The process of negotiating access to care can take weeks or months, creating significant delays in accessing antenatal care.

    —  Women have experienced aggressive treatment from the Overseas Visitor Manager. Some have experienced harassment.

    —  Women have been contacted by debt collectors prior to the birth.

    —  Women who are entitled to free care have been wrongly denied free care because trust staff did not understand Home Office information.

    —  Overseas Visitor Managers have met with women who speak little or no English to discuss their entitlement without use of an interpreter, resulting in confusion.

  As a result of this policy, many vulnerable women commence antenatal care late, receive intermittent care, or receive no antenatal care and attend only for the birth. There is also evidence of women giving birth alone and unattended (Kelley & Stevenson 2006). Suboptimal antenatal care is a major risk factor for maternal deaths and was present in 19% of maternal deaths investigated in the Confidential Enquiry into Maternal and Child Health report, Saving Mothers' Lives (Lewis 2007a). Antenatal care provides opportunities to identify and treat conditions including pre-eclampsia, eclampsia, gestational diabetes, and cardiac disease. The risk of a child being born with HIV is reduced from 30% to 1-2% if a HIV positive mother receives appropriate treatment.

  The CEMACH report recommended improvements in service accessibility to promote early commencement of antenatal care (Lewis 2007a). The importance of this issue is reflected in the selection of indicators for the 2007 Public Service Agreements. Delivery Agreement 19, Indicator 4 is "the percentage of women who have seen a midwife or a maternity professional for health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy". It is not possible to reconcile the current focus on promoting improved access to antenatal care with the policy of charging for maternity care.

  At present, there is a strong financial disincentive for trusts to provide care to women who are not entitled to free NHS care. The trust is obliged to provide care to women who cannot pay for care, but there is no source of funds to cover this obligation. The introduction of Payment By Results means that the costs cannot be absorbed into block contracts. As a result, there is a financial penalty for trusts which provide maternity care to this group of vulnerable women.

3.2  Proposals to deny eligibility to free NHS primary care to vulnerable migrants

  At the time of writing, a joint Department of Health and Home Office review was considering proposals to extend the current charging regime to primary medical services. This would have the effect of denying eligibility to free NHS GP services to vulnerable migrants, including refused asylum seekers, trafficked women and undocumented migrants.

  The review was announced in a Home Office document, Enforcing the Rules (Home Office 2006) which described one of its aims as:

 to ensure that living illegally becomes ever more uncomfortable and constrained until they leave or are removed.

    This sits in contrast with the rationale for the 2004 regulations on charging for secondary care, which was to combat perceived abuses of the NHS by "health tourists".

  While government policy supports direct access to midwives, 83% of women first seek pregnancy care from their GP (Redshaw et al 2006). This rises to 86% for women having their first child. Charging for GP services may result in vulnerable migrants delaying the commencement of maternity care or not seeking it at all. Given evidence that vulnerable women are already being deterred from obtaining maternity care by requests for payment by maternity services, charging for GP appointments is likely to increase the proportion of women who do not obtain satisfactory antenatal care. Another deterrent factor is the increase in data sharing which is anticipated to accompany this policy, as this will add to women's fears that attending for care will bring them to the attention of immigration authorities.

  The CEMACH report emphasised the importance of identifying any underlying health problems early in pregnancy, and recommended that women who are new to the UK undergo a full medical examination by a suitably trained doctor, such as the woman's GP (Lewis 2007a). It is unclear whether this would be considered part of maternity care and therefore "immediate and necessary" care. If this is not the case, then vulnerable migrants may be unable to obtain this examination unless they can pay. This places an already vulnerable group of women at further risk.

  Charging for GP services also reduces the very limited support available to vulnerable migrants who are experiencing domestic violence. Women who are vulnerable migrants have particular difficulties in leaving an abusive partner. Women who are failed asylum seekers or undocumented migrants are not entitled to access emergency accommodation or receive welfare benefits. They may be left with the choice between remaining in an abusive relationship or destitution.

  GPs provide an important source of health care to women experiencing domestic abuse and may assist in linking her to sources of support. Vulnerable migrants who are experiencing domestic abuse may not be able to obtain money from their partner or family to pay for GP appointments and so may lose this source of support.

  For many women who are legally resident in the UK, their right to remain in the UK is dependent upon their husband. If they leave the relationship, they face deportation. For some women, deportation back to their countries of origin may mean violence and persecution for being divorced or separated. Many new migrants have, as a condition of their visa, "no recourse to public funds". Women with "no recourse to public funds" are not entitled to access emergency accommodation, including women's refuges and are not entitled to receive welfare benefits. Leaving the relationship may leave them destitute.

  Women with "no recourse to public funds" who are escaping an abusive relationship may gain the right to remain in the country if they can provide evidence of the abuse. A letter from a GP is one of the few forms of evidence which is acceptable to the Home Office. Currently, women with "no recourse to public funds" are entitled to free GP appointments. If these women were to be charged to attend a GP appointment, they may not be able to prove to the Home Office that the abuse occurred.

3.3  Interpreters

  Language support is fundamental to the provision of high quality health services to vulnerable women with limited or no English. Despite this, there are ongoing problems with provision of interpreting services including inappropriate use of family members to interpret and failure to use interpreters.

  The CEMACH report documented the risks to patient safety associated with unsatisfactory language support (Lewis 2007a). In 34 of the 295 maternal deaths investigated, the women spoke little or no English and very few had access to interpreting services. Five women who were murdered by their partners had the abusive partner as their interpreter. In one case, diagnosis of tuberculous meningitis was delayed as the husband was acting as the interpreter. An asylum seeking woman who died from a complex set of conditions had her young son translating for her. Disturbingly, a GP reported that interpreting was a particular problem in his practice as there was no agreed source of funding for interpreters.

3.4  Female Genital Mutilation or Cutting (FGM/C)

  The number of women with Female Genital Mutilation or Cutting (FGM/C) living in England and Wales is in excess of 66 000 (Dorkenoo 2007). This figure is expected to increase, largely due to migration from countries where it remains common practice. Despite the availability of education resources for healthworkers, awareness of the issue and standards of maternity care for women with FGM/C is variable.

  Examples of unsatisfactory care for women with FGM/C are documented in the CEMACH report (Lewis 2007a). For one woman, late identification of FGM/C led to an unnecessary caesarean section and may have directly contributed to her death.

3.6  OTHER POLICY AREAS CONTRIBUTING TO HEALTH INEQUALITIES

3.6.1  Destitution for refused asylum seekers

  The Government's policies and practices in relation to support for asylum seekers and refused asylum seekers have been widely criticised as inhumane and in breach of human rights. The Joint Committee on Human Rights inquiry into the treatment of asylum seekers (2007) concluded:

    We consider that by refusing permission for most asylum seekers to work and operating a system of support which results in widespread destitution, the treatment of asylum seekers in a number of cases reached the Article 3 ECHR [European Convention on Human Rights] threshold of inhuman and degrading treatment . . Many witnesses have told us that they are convinced that destitution is a deliberate tool in the operation of immigration policy. We have been persuaded by the evidence that the Government has indeed been practicing a deliberate policy of destitution of this highly vulnerable group.

  The health impact of these policies is severe. A national study involving 125 asylum seekers found that many had experienced deteriorating health and a permanent state of depression, distress and anxiety (Refugee Action 2006). A study undertaken in Leeds concluded that destitution policies can have an acute impact on the wellbeing of refused asylum seekers and can lead to self-harm and suicidal thoughts (Lewis 2007b).

  Of particularly concern is "section 9", which enables the Home Office to cease providing support for an asylum seeker with a dependent child if the family is not considered to have taken reasonable steps to leave the UK. In these circumstances, the local authority may take the child into care. According to Refugee Action, four children were taken into care during a pilot of section 9 in 2005 and a substantial number of families "disappeared" from their accommodation(Joint Committee on Human Rights 2007). These outcomes are manifestly not conducive to the good health of parents or children.

3.6.2  No recourse to public funds and domestic violence

  The policy of providing "no recourse to public funds" to many new migrants creates significant problems for women experiencing domestic violence. Women with "no recourse to public funds" are not entitled to access emergency accommodation, including women's refuges and are not entitled to receive welfare benefits. They are forced to choose between remaining in an abusive relationship or destitution if they leave the relationship.

  This has particular implications for maternal health. It is estimated that 600 women who have insecure immigration status are subject to domestic violence from their spouse each year (Southall Black Sisters & Women's Resource Centre 2005). Women who are pregnant are at particular risk of domestic abuse. In approximately 30% of domestic violence cases, the abuse began during pregnancy (Department of Health 2005). Of the 295 maternal deaths examined in the CEMACH report, 19 of these deaths were of women murdered by abusive partners (Lewis 2007a). 70 of the 295 women who died had features of domestic abuse (Lewis 2007a).

4.  TERM OF REFERENCE

6:   The effectiveness of the Department of Health in co-ordinating policy with other government departments, in order to meet its Public Service Agreement targets for reducing inequalities

  The relevant PSA target for the current period is the infant mortality target:

    Starting with children under one year, by 2010 to reduce by at least 10% the gap in mortality between the routine and manual group and the population as a whole

  The relevant PSA for the CSR07 period of 2008-2011 is:

    PSA Delivery Agreement 19, Indicator 4: The percentage of women who have seen a midwife or a maternity professional for health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy

4.1  Department of Health and Home Office policy coordination

  Proposals to deny eligibility to free NHS primary care to vulnerable migrants, discussed at 3.2 above, are part of a joint Home Office/Department of Health review. As discussed above, the proposals under consideration in this review are likely to reduce timely attendance for maternity care and, consequently, are likely to have a negative impact on infant mortality. While there appears to be a high level of coordination between the Department of Health and the Home Office, this is not conducive to meeting PSA targets.

January 2008

REFERENCES

  Department of Health, 2005, Responding to domestic abuse: a handbook for health professionals.

  Department of Health, 2007, Review of the health inequalities infant mortality PSA target, COI: London.

  E. Dorkenoo, L. Morison & A. Macfarlane, 2007., A statistical study to estimate the prevalence of Female Genital Mutilation in England and Wales, Forward: London.

  S. Hargreaves, J.S. Friedland, A. Holmes, & S. Saxena, 2006, The identification and charging of Overseas Visitors at NHS services in Newham: a Consultation, Newham Primary Care Trust & Imperial College: London.

  Home Office, 2007, Enforcing the rules: a strategy to ensure and enforce compliance with our immigration laws.

  Joint Committee on Human Rights, House of Lords and House of Commons, (2007), The treatment of asylum seekers: tenth report, HMSO: London.

  N. Kelley & Stevenson, 2006, First do no harm: denying health care to people whose asylum claims have failed, Refugee Council: London.

  G. Lewis (ed), 2007a, The Confidential Enquiry into Maternity and Child Health (CEMACH) Savings Mothers' Lives: reviewing maternal deaths to make motherhood safer 2003-2005 The Seventh Report on Confidential Enquiries into Maternity Deaths in the United Kingdom, CEMACH: London.

  H. Lewis, 2007b, Destitution in Leeds, Joseph Rowntree Charitable Trust: York.

  National Health Service (NHS), 2004, Implementing the Overseas Visitors Hospital Charging Regulations: Guidance for NHS Trust Hospitals in England, COI: London.

  Project London, 2007, Project London: Report 2006, Medecins du Monde: London.

  M. Redshaw, R. Rowe, C. Hockley, & P. Brocklehurst, Recorded delivery: a national survey of women's experience of maternity care 2006, National Perinatal Epidemiology Unit.

  Refugee Action, 2006, The Destitution Trap: Asylum's untold story.

  Southall Black Sisters & Women's Resource Centre, 2005, How can I support her? Domestic violence, immigration and women with no recourse to public funds, Southall Black Sisters & Women's Resource Centre: London.






 
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