Modern Slavery Bill

Written evidence submitted by Doctors of the World (MS 24)

Doctors of the World UK, part of the Médecins du Monde network, is an international humanitarian organisation providing healthcare to vulnerable populations in both developing and developed countries. In the UK, we run a volunteer-led clinic, outreach and advocacy project that helps the most vulnerable members of the community to get the healthcare they need. We work primarily with migrants, including asylum-seekers, homeless people, domestic workers and sex workers.

In the UK and overseas we encounter both victims of, and conditions in which people are vulnerable to, trafficking, slavery and other forms of exploitation. We very much welcome the opportunity provided by this Bill to give greater attention to the suffering, needs and rights of victims of modern slavery, to increase protections against such exploitation and to improve the opportunity and support for victims to escape and recover from it.

Taking a victim-centred approach

1. The lack of scruples on the part of traffickers and slave masters in exploiting any means to control their victims necessitates a victim-centred focus at the heart of all policy and practice.

2. That victims have access to healthcare is of especial importance both to protect their health and because it offers an opportunity whereby they may secure advice and support to escape their abuse. In April 2013, the then Public Health Minister, Anna Soubry MP, upon launching a programme of training and advice for NHS staff to identify and support victims of trafficking, said [1] :

"Surgeries and hospitals are sometimes the only place where victims come into contact with people who care and are concerned for their welfare so it is vital that we make the most of these opportunities."

3. The Minister is right. But for such initiatives to be effective, it is vital that victims are able, and feel able, to go to surgeries and hospitals, i.e. that healthcare services are accessible to victims. Any yet, for the many victims whose immigration status is irregular, access to healthcare is both restricted and deterred by NHS charges and the fear that seeking to access healthcare services will lead to their being reported to immigration authorities.

NHS charges for healthcare

4. Although there is currently an exemption from NHS charges for victims of trafficking, this only applies to those formally accepted as victims or potential victims by the National Referral Mechanism. [2] Thus, for very many victims, charges for healthcare services apply. For example, in 2012 around two-thirds of trafficking victims identified by the Serious Organised Crime Agency (SOCA) had not been referred to the National Referral Mechanism [3] . There will of course also be other victims who have not come into contact with SOCA and who have not been recognised.

5. The Government has acknowledged the inadequacy of the exemption and has committed to examine how to address this inadequacy, [4] but it is yet to confirm that all victims will have free access to healthcare or identify how that goal may be achieved.

6. Whilst certain services are currently available to all for free [5] - e.g. primary care and Accident & Emergency – the Government is to introduce charges for these services. [6] If the Government extends NHS charges as it has indicated, a victim of trafficking who has not been formally recognised by the National Referral Mechanism will no longer have free access to the following: Accident & Emergency, walk-in clinics, minor injuries units, and family planning services including for a termination. While he or she will be entitled to free GP consultations if able to register with a GP surgery, other primary care services will not be free. [7] If diagnosed with a communicable disease or sexually transmitted infection, he or she will be entitled to free treatment for the infection, [8] but where and how will a victim as yet unidentified and unrecognised obtain a diagnosis?

7. Irregular migrants living with infections such as HIV tend not to proactively seek a diagnosis –a GP’s recommendation of screening in the course of providing other treatment is often vital. [9] A victim’s situation of slavery may mean he or she is not able to register with a GP. Even if not precluded, he or she may face – like many other irregular migrants – considerable difficulties in seeking to register. [10] But even if successful, and hence eligible for free consultations, the Government – having been asked directly – has declined to confirm that GPs will be permitted to undertake all necessary diagnostic testing for free and/or provide any free treatment. [11] Even if a victim can register with a GP, what will be the point in attending a GP who is not permitted to take any positive action unless for a charge, which a victim is highly unlikely to be able to pay?

Fear of the authorities prevents engagement

8. The overwhelming majority of victims of trafficking are foreign nationals, and a substantial majority are from outside the European Economic Area. Having an irregular immigration status is a key factor in victims’ fear of authorities, and this is often exploited by traffickers and slave masters to further their control over victims. [12]

9. A key reason for this is that when victims come to the attention of authorities, their irregular immigration status is often immediately or quickly identifiable whereas their status as a victim is not. And recognition of the former tends to determine the response of the authority. Since this often involves the threat or actuality of arrest, removal and/or criminalisation, the fears of victims about engaging with authorities are essentially confirmed. The testimony of senior and junior police officers confirms this pattern – e.g. Deputy Chief Constable Giles York: [13]

"One girl escaped from a brothel and went to a police station to tell them that she had been trafficked. She had no passport. Under these confusing circumstances, we chose to arrest her for being an illegal immigrant."

10. The risk that victims of modern slavery will be deterred from accessing healthcare by NHS charges will be increased by any perception that seeking healthcare will or may entail being reported to immigration authorities. Similar concerns have persuaded the Government to make express in Clause 44(3) of the Bill that notification of adult victims to the National Crime Agency must be anonymous unless the victim gives consent to be identified. [14]

11. We have encountered service users deterred from accessing healthcare by an express threat that they will be reported to the Home Office, though there is no routine requirement for this and it plainly undermines any healthcare provider-patient relationship – indeed data from our clinic in East London shows that one in five of our service users who have not attempted to access healthcare have been deterred by the fear of being reported or arrested. [15] There is a further risk that the planned registration system [16] by which NHS providers are to be expected to check on a patient’s immigration status will exacerbate these risks and fears.

12. The Government’s planned extension of NHS charges for overseas visitors risks creating in the NHS the same disabling environment that has afflicted the police, in which the response to a victim (particularly when it is not immediately clear or understood he or she is a victim) is determined by his or her irregular immigration status.

New Clause amendment

13. The Minister’s announcement in April 2013 recognised two critical things. Firstly, healthcare workers can play a vital role in identifying and supporting victims of trafficking and other slavery – if victims have access to healthcare services. And yet NHS charges, and the fear of being reported to authorities, both act as significant deterrents.

14. Secondly, to have real effect, any commitment to ending the appalling abuse experienced by victims must ensure that sources of social and institutional support and compassion are not withheld – whether by design or as an unintended consequence – until victims are identified, self-identify or are formally accepted as victims.

15. This clause would enable a healthcare provider to provide free healthcare to suspected victims of slavery or human trafficking. This would reduce the deterrent effect of charging on access to healthcare thereby supporting an environment of trust and confidence and enable ongoing engagement with the suspected victim to the benefit of the victim’s health and chances of being assisted to escape abuse.

Mr David Burrowes NC35

Sarah Teather

"Provision of NHS services to victims of modern slavery

Where a provider of services, to which section 175 of the National Health Service Act 2006 relates, believes that a person may be a victim of slavery or human trafficking, no charge may be made under that section for services from that provider to that person."

September 2014


[1] See

[2] NHS (Charges to Overseas Visitors) Regulations 2011, SI 2011/1556, regulation 12

[3] SOCA, A Strategic Assessment on the Nature and Scale of Human Trafficking in 2012 , 2013,

[4] D oH , Sustaining services, ensuring fairness: Government response to the consultation on migrant access and financial contribution to NHS provision in England , 2013,

[5] NHS Regulations op cit , regulation 6

[6] D oH , Visitor & Migrant NHS Cost Recovery Programme: Implementation outline , 2014,

[7] D oH I mplementation outline opt cit – While there is some suggestion that certain of these services (e.g. walk-in clinics and minor injuries units) may not in all circumstances be chargeable, any charging is likely to have a deterrent effect as victims are unlikely to either be familiar with these or have confidence that any relevant distinctions will be exerci sed in their favour .

[8] Hansard HL, Immigration Bill Committee, 10 Mar 2014 : Column 1578 per the Lord Taylor of Holbeach

[9] This is well recognised in relation to HIV infection, and is consistent with our experience. L ate diagnosis is exacerbated by concerns about confidentiality and trust in GPs, but diagnosis via GPs is increasingly important e.g. Burns, F M et al , Missed opportunities for earlier HIV diagnosis within primary and secondary healthcare settings in the UK , AIDS 2008, 22: 115-122

[10] Many services users at our east London clinic have been refused registration with a GP surgery for reasons including that they have no settled address, have difficulty confirming their address, have no passport or other document identifying their immigration status or that they will be charged or reported to the immigration authorities.

[11] Q uestions put by the Baroness Cumberlege and the Baroness Barker, Hansard HL, Immigration Bill Committee, 12 Mar 2014 : Columns 1838 & 1840

[12] Joint Committee on the Draft Modern Slavery Bill, Draft Modern Slavery Bill , Report of Session 2013- 14, HL Paper 166/HC 1019, 2014,

[13] CSJ , It happens here: Equipping the United Kingdom to fight modern slavery , 2013, pp83-85

[14] Joint Committee on Draft Modern Slavery Bill’s report op cit and Government response to that report, Cm 8889, 2014

[15] Médecins du Monde, Access to healthcare of excluded people in 14 cities of 7 European countries , 2013,

[16] Department of Health implementation outline op cit , pp14-18

Prepared 15th October 2014