Examination of Witnesses (Questions 67-79)
DR ANGELA
BURNETT, MS
KAREN MCCOLL
AND DR
YUSEF AZAD
4 DECEMBER 2006
Q67 Lord Plant of Highfield: Good afternoon.
Perhaps I should explain to begin with that the normal Chairman
of this Committee, Mr Andrew Dismore, who is the MP for Hendon,
is involved in the report stage of a Bill going through the House
of Commons on corporate manslaughter. He has an amendment which
is currently being debated, so he is in the Chamber and I am standing
in for him. First of all, perhaps you can identify which organisation
you represent, starting with Dr Burnett.
Dr Burnett: My name is Angela
Burnett, and I am representing Medact. Do you want me to say something
about Medact?
Q68 Lord Plant of Highfield: Let
us go to the individuals first.
Ms McColl: My name is Karen McColl.
I am the Director of Medecins du Monde, UK. It is the UK branch
of an international medical and humanitarian organisation. Since
January this year we have been running a health project in London
called Project London to improve access to healthcare for vulnerable
migrants.
Dr Azad: My name is Yusef Azad.
I am Director of Policy at the National AIDS Trust.
Q69 Lord Plant of Highfield: I do
not know whether you would like to make some sort of general comment
at the beginning of your evidence, either individually or collectively?
If you do, we would be grateful if it could be reasonably brief
because we have got quite a large number of questions to ask,
but do feel free if you would like to say something.
Dr Burnett: I am happy to leave
time for questions.
Q70 Lord Plant of Highfield: Are
all of you?
Ms McColl: Yes.
Dr Azad: Yes.
Q71 Lord Plant of Highfield: If I
can ask the first couple of questions. This is to Medecins du
Monde. You stated that the regulations prevented refused asylum
seekers from accessing hospital treatment and that may interfere
with their human rights, particularly to the right to life under
Article 2. Can you expand on that claim a bit?
Ms McColl: Medecins du Monde has
been concerned with other interested groups for some time about
access to secondary care since the regulations were changed in
2004 in terms of charges for overseas visitors. What we are concerned
about is the impact on people who are already living here. Through
the work of other agencies and of our own Project London we have
case studies of people who have been refused access to secondary
care even when they are quite seriously ill or even if they are
in particular risk groups, such as pregnant women. We think that
infringes their right to health or the right to the highest attainable
standard of health under Article 12 of the International Covenant
on Economic, Social and Cultural Rights and possibly, in some
cases, the right to life or the right to freedom from inhumane
or degrading treatment.
Dr Azad: We would certainly agree
and, obviously, as the Committee will know, HIV without treatment
ultimately results in death, so Article 2 is involved, but also
Article 3 because without treatment the individual suffers an
increasing range of really severe and distressing opportunistic
infections, so both of those Articles apply. We should obviously
concentrate on the human rights of the asylum seeker, but there
is another aspect I would briefly like to mention around public
health. If you look at Article 12 of the International Covenant
on Economic, Social and Cultural Rights, one thing that state
parties should do is take steps necessary for `the prevention,
treatment and control of epidemic diseases'. One of our concerns
also is that there are human rights for vulnerable communities
and the general population which are being undermined by untreated
HIV and untreated TB being allowed to occur in the community.
Dr Burnett: I would certainly
echo what my colleagues have said. I know of several cases where
people have been suffering from cancer, from multiple sclerosis
and other serious degenerative diseases. Obviously withholding
treatment will definitely lead to deterioration and ultimately
death. I also support the fact that it is not just the individual,
but also it is an important public health issue.
Ms McColl: If I could add one
other point, it is important to add that there is no safety net,
there is no alternative, for people if they are able to access
NHS care and they are unable to pay for it privately. It is precisely
because the NHS has operated with this principle of universal
access that we have never until now needed a safety net. In other
European countries where they have different systems they maybe
have an alternative system in place to act as a kind of safety
net but we have never needed one and now find we do need one.
Q72 Lord Plant of Highfield: And
there is not a predictable safety net? Is there anything by and
large and on the whole informal that people do even though there
is no statutory free safety net? What does happen? Are people
with TB and AIDS just not treated at all or are there informal
ways in which treatment is given?
Dr Azad: Certainly with regard
to HIV, it is a highly complex and specialist treatment. There
is no informal system other than that provided by the NHS. What
happens is that people disappear from care and we are getting
an increasing number of cases where that is happening, often when
they are co-infected with TB, so there are implications, obviously,
both for their own health and for wider society. The Department
of Health will say that they meet the point about Articles 3 and
2 through the requirement that where the clinician deems treatment
to be immediately necessary it should be given. The person nevertheless
is not free of charges. The person is allowed to access the treatment
but the bill comes at a later date. I suppose our fundamental
contention is that this does not meet the requirements of the
European Convention because, whether it is a pregnant mother living
with HIV or someone with another serious and life-threatening
disease, the prospect of a bill for thousands of pounds when they
are, as we have just heard, very often destitute and without any
funds or resources is enough to deter people from accessing the
life-saving treatment they need or to end accessing treatment
they were accessing previously.
Dr Burnett: As well as being technically
impossible to treat complex illnesses outside a properly structured
health service, the care needs to be co-ordinated, and if we are
thinking about infection and infectious diseases people need to
be completing the course of treatment; otherwise that leads to
resistance of the infections and we already have that in certain
cases with TB. We certainly do not want to increase that. There
is an important requirement on the Department of Health to carry
out both a public health impact assessment and a race impact assessment
of these policies, and neither of those has happened.
Q73 Lord Plant of Highfield: In a
sense you have brought me on to my next question which is that
from several organisations there have been suggestions of widespread
confusion about the rules for access to free secondary healthcare.
In the case of Médécins du Monde, in your evidence
you refer to cases where patients are being discriminated against,
refused treatment and charged in error, and we have heard about
discrimination in another sense just now from Dr Burnett. How
widespread do you think these problems are?
Ms McColl: Our findings from Project
London can only really be seen as a small snapshot because it
has only been running for 10 months and it is a relatively small
project. The worry is that they represent a much wider picture.
The rules on access to secondary care are now very complex and
we are seeing a lot of confusion on the ground, particularly about
what constitutes immediately necessary treatment and how to define
that, in particular around the area of maternity care which the
Department of Health has said should always be considered as immediately
necessary and women should not be refused treatment on the basis
that they are unable to pay, but we and other organisations have
come across women who are being asked to pay 100% deposit for
an antenatal package before they can have any care at all.
Q74 Lord Plant of Highfield: Do you
have anything to add, Dr Azad?
Dr Azad: Simply to agree. We have
a number of cases where people with a live and legitimate asylum
claim have been charged. We have a number of cases of pregnant
women with HIV being told that they have to pay up front, which
is contrary to the directive from the Department of Health on
immediately necessary treatment in those cases.
Q75 Lord Plant of Highfield: Dr Burnett?
Dr Burnett: As well as being extremely
traumatic for the individuals involved, it is very cost inefficient
to the Health Service to let conditions deteriorate There are
several examples, and perhaps I may pick out one which was mentioned
by the Refugee Council in their report of a woman who was pregnant,
who was presented with a bill, was unable to pay it and did not
access further antenatal care, delivered her baby by herself at
home and the baby then required intensive care on a specialist
baby care unit, which obviously cost thousands of pounds. This,
I would suggest, might have been avoided had she had properly
attended antenatal care and delivery.
Q76 Nia Griffith: Dr Azad, you mentioned
in particular clients who have HIV who are not asylum seekers
but have applied for the right to stay in the UK under Article
3 of the Human Rights Convention. You say they have been refused
secondary care because they are not defined as asylum seekers.
In the case of HIV is it possible to refuse treatment without
breaching human rights?
Dr Azad: In our view it is not
because we know that HIV is a life-threatening condition and so
we think, both in terms of the International Covenant and indeed
the European Convention, to deny treatment that is available to
someone which would save their life is inhumane and contrary to
their human rights. The strange thing about Article 3, and this
applies also to people on section 4 NASS support, is that these
are people who are receiving state funding, albeit it may not
be enough (and we have heard something of that), in terms of accommodation,
in terms of welfare, and so I think they must be deemed to be
lawfully resident while their claims are being considered and
yet they are being denied secondary care. There is nowhere else
for them to go. There is no safety net, as we have heard, so they
are put in an impossible position. We have written to the Minister
asking that the guidance be clarified so that the assumption that
we had all had until a recent Department of Health communication,
that Article 3 applicants were deemed to be in the same position
as asylum seekers, was correct and that that might be the guidance
that is disseminated and these people are brought within the system.
Dr Burnett: I want to point out
another anomaly, which is that DFID is very actively campaigning
for universal global access to anti-retroviral treatment and yet
here in the UK a group of people who are extremely vulnerable
are being denied treatment.
Dr Azad: I was talking to the
World Health Organisation in Europe who have a responsibility
for monitoring universal access to treatment, and they have made
it quite clear that according to the WHO rules the UK has not
complied with universal access to HIV treatment which, given the
G8 Gleneagles commitments, is a sad state of affairs and we hope
it can be put right soon.
Q77 Nia Griffith: Dr Burnett, you
have already mentioned a good number of the difficulties. Is there
anything else that you would like to add about the effect that
the restrictions on hospital treatment care are having on those
asylum seekers who are entitled to treatment and what difficulties
you face in ensuring that asylum seekers receive adequate medical
treatment?
Dr Burnett: The first part of
your question was about the effect on people who do have access?
Q78 Nia Griffith: The effect the
restrictions are having on those asylum seekers who are entitled
to treatment and the difficulties that you face in ensuring that
asylum seekers receive adequate medical treatment.
Dr Burnett: In answer to the first
part, I think it is leading to a huge amount of confusion and
there are many examples where people who still have an active
asylum case and therefore are entitled to treatment are being
denied care. In answer to the second part, it is taking an increasing
amount of health workers' time in advocating to ensure that people
who are vulnerable can receive care. As you are well aware, health
workers are extremely pressed and I think it is time which would
be better spent providing care, not only for this group but also
for all the other patients who are registered with us, and I think
it is leading to many problems.
Q79 Dr Harris: I should say that
I am a member of the British Medical Association and specifically
a member of the Medical Ethics Committee that gives advice to
doctors on ethical areas. I want to ask Dr Burnett first about
primary care and the discretion that you have as a GP and your
colleagues have as GPs whether or not to register as a patient
a refused asylum seeker or other migrant who does not have legal
status in this country. How in your experience is this discretion
applied in practice, both in your own area and from your organisation
in other areas of the country, where seeing people present for
primary care might not be quite so common as in your area, and,
secondly, what do you think the quality of professional advice
or guidance is, for example, from the BMA or indeed the Department
of Health?
Dr Burnett: First I should say
that I myself am a practising GP. I work in Hackney at the Sanctuary
practice, which was set up specifically to cater for refugees
and asylum seekers, and I also work at the Medical Foundation
for the Care of Victims of Torture. Certainly in the Sanctuary,
which is part of the NHS, we do use our discretion to register
people but I know that there are other practices which also are
able to refuse to register and that is in the guidance. I think
that Karen from Médécins du Monde will talk a lot
about the difficulties of registering people and often we will
register someone who has been rejected by several other practices.
The clarity of the guidance I think leaves something to be desired.
The actual wording from the Department of Health appears to be
directly contradictory, where they advise GPs not to register
people who have failed in their claim but subsequently they say,
"You do have discretion to do that". I think that the
guidance should be made clearer and I think that GPs should be
encouraged to register people because, as I have said before,
I think it makes no public health sense and also no sense for
the individual.
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