Examination of Witnesses (Questions 80-99)
DR ANGELA
BURNETT, MS
KAREN MCCOLL
AND DR
YUSEF AZAD
4 DECEMBER 2006
Q80 Dr Harris: So, in terms of the
discretion being applied, how many practices are doing this in
your experience? Do they lose out financially if on an individual
case they are simply unable to claim for that and does that have
a significant impact on their budget?
Dr Burnett: Yes, I think it would
have a significant impact on their budget because more and more
GP income is dependent on reaching targets and for this group
of people it is quite hard to achieve those targets, partly because
they are very mobile, partly because the sorts of illnesses that
they present with are not reflected in the Quality and Outcomes
Framework which forms a very significant part of general practice.
Q81 Dr Harris: But if they have 100
on the list they get funded on the list so they do get funding
for those 100 even if they are not—or do they not?
Dr Burnett: They would get some
funding, but I think the funding is inadequate for the amount
of work which is needed. The amount of work includes, as I have
said, the amount of advocacy that is needed, which is not the
individual person's fault, and also the issue of interpreting,
the fact that consultations take longer. I think this needs to
be valued. At the moment it is penalised.
Q82 Dr Harris: I am going to come
on to the project in a later question so we can hold off that,
but is it your view that any medication given in primary care
that is not immediately necessary or urgent, for example, treating
a diabetic to control their blood sugar, is something that is
immediately necessary or urgent or would you consider that to
be non-urgent?
Dr Burnett: No, I would consider
that completely essential.
Q83 Dr Harris: I mean with tablets.
Dr Burnett: Yes, because if diabetes
is untreated that leads to short-term, often emergency situations,
and also long term complications. Asthma is another example.
Q84 Dr Harris: What about HIV from
a clinical point of view because in some countries they do not
treat until they are symptomatic or they have a CD4 count that
is low enough but in some countries they treat anyway?
Dr Burnett: I think treating HIV
promptly reduces the incidence of complications and also reduces
infectivity.
Q85 Dr Harris: I would like to ask
Yusef, you state in your evidence that if the restrictions on
secondary healthcare were extended to primary healthcare there
would be "obvious implications for public health", with
more people attending A&E departments as well, and particularly
human rights concerns in relation to children. Can you expand
on what you mean by those consequences or concerns?
Dr Azad: It is apparent even at
the moment that there are real difficulties, even for asylum seekers
and even more so for failed asylum seekers, in accessing primary
care, and that includes families and it includes families with
children. I do not think we are totally clear what the rights
of children are in this context but even if in theory for children
their care would not be charged under a charging regime the problem
is registering with a GP in the first place and getting the children
to be seen by a GP and getting their healthcare monitored. The
Health Protection Agency produced a report on migrant health last
week where they wrote, "Primary care practitioners may be
ideally placed to consider HIV risk in their assessment of a patient's
health needs as a new entrant to the UK and need to be supported
in this role". One problem is that the more barriers you
put up for primary care the less likely it is that children who
may have health needs will be identified. Another loss is the
key opportunity to identify people with possible life-threatening
symptoms, be it HIV or some other very serious condition. Care
in Accident & Emergency remains free of charge. The more you
create barriers for people to access a GP the more they are simply
going to present, if they really feel ill or concerned about their
health, at the one place where they know they can get free healthcare,
so all the achievements and successes there have recently been
in terms of reducing Accident & Emergency times are going
to be undermined by that being, as it were, the place of last
resort to which people go, often with conditions and issues that
really are not appropriate for Accident & Emergency settings.
Those are all issues around primary care access at present and
the possible further harmful effect of charging.
Q86 Dr Harris: Do you think there
is already evidence, and maybe there is no evidence or it has
never been looked for, that people are not being diagnosed with
an infectious disease like HIV and TB and therefore as a consequence
not only are there, because you have covered this, implications
for them in terms of treatment, but there are also further infections
from that primary case? Has that been looked for and is there
any evidence?
Dr Azad: The evidence suggests
that 33-50% of people diagnosed with HIV have previously presented
in a GP surgery with HIV-related symptoms and they have not been
noticed or identified.
Q87 Dr Harris: Can you give us a
reference for that at a later date?
Dr Azad: Yes, certainly. It is
in a document called Treat with Respect by a number of
HIV clinicians[1].
Primary care is already, in terms of infectious disease, too often
(certainly in terms of HIV) a serious lost opportunity. The Government,
quite rightly, is trying to reverse that process, up-skill GPs
and make primary care a place where HIV symptoms can be identified,
where people can be referred for tests or indeed be tested. The
problem is that at the same time many of the people living with
HIV from the relevant community are being denied access to primary
care settings and so there are two policies at cross purposes
here. Another problem is that the way HIV services are designed
is being reconfigured. To date most people living with HIV have
been able effectively to get a one-stop-shop health service at
their HIV clinic. Given the way the NHS is changing that is no
longer the case and it is increasingly the case that someone living
with HIV will just get their very specialist care in the HIV clinic
and will need to go for all ancillary care to a GP. People living
with HIV who find it difficult to register with a GP are suddenly
going to find a loss of care that they were enjoying access to
in an HIV clinic. They will no longer be able to access this care
because they are having difficulty registering with a GP.
Q88 Dr Harris: My question is also whether
you think it is possible or likely that third parties are being
infected with infectious diseases as a result of the policy that
causes delay in diagnosis and treatment?
Dr Azad: I think that is both
possible and likely. People are at their most infectious in the
early stages of HIV infection around seroconversion. Often people
will present in GP surgeries with very severe `flu-like symptoms
which are actually signs of seroconversion illness and at that
point the person is at their most infectious. If GP surgeries
could be used to pick up the relevant risk factors, identify the
possibility of HIV seroconversion and test and treat then there
could be a very significant impact on HIV transmission in this
country.
Q89 Dr Harris: If I may turn to Médécins
du Monde, with regard to your project you give examples in your
evidence of people having difficulty registering because of the
need to provide ID. What could be done to remedy that? You have
already mentioned there is no racial impact assessment from some
of these measures which might have picked up that potential problem
but could you say what you think ought to happen to remedy that
problem?
Ms McColl: First of all, as you
mentioned, there are no regulations limiting access entitlement
to primary care and it remains at the discretion of the GP but,
as we have heard, there is a certain lack of clarity in terms
of the guidance on that. We think the Government should make it
clear that there is a return to the basic principle of the NHS
that healthcare should be available to everybody living in this
country and that that should extend to primary care. We would
also like to see more flexibility on the part of practices in
terms of the documents that they accept as proof of address or
enable someone to be able to register with a practice. For the
clients who come to our project it is just out of the question
for them to have access to a bank statement or a utility bill
to be able to prove their address, and for some practices those
are the kinds of documents that they require and there is a real
lack of flexibility about accepting other documents. For people
who are in unstable accommodation, who may have lost all their
documents during their flight or have had them kept by former
employees it is just impossible to have all those documents, so
we would really like to see more flexibility and we reinforce
what Yusef said, that the Health Protection Agency's report on
migrant health really emphasised the importance of primary care,
not just in HIV but in supporting the health needs of migrants.
Q90 Dr Harris: Your examples cover
what could be described indirect discrimination but do you have
any evidence, and could this be tested, about whether there is
direct discrimination, that people who look foreign in certain
places are being told the list is closed, whereas if you or I,
if I could number you as a transgressor, were to seek entry to
the list you might be told that there was not a problem? Is there
any evidence of that?
Ms McColl: We do not have direct
evidence of that. It could be tested. You could set up some way
to test it but all we are reporting is the findings of our clients
who come to our project, so we do not have direct evidence of
that.
Q91 Dr Harris: In your examples you
give a series of excuses that are provided around, "We do
not have interpreters", when in fact they do have access
to interpreters.
Ms McColl: That is right. We have
cases where the excuses have changed. As we try to overcome one
barrier, such as the lack of interpreters and we have said, "The
PCT is providing interpreter support", then the excuse became,
"The list is full", and then the excuse became, "We
do not have enough staff". It was quite clear that that particular
practice did not want to register that particular person. We can
say that.
Q92 Baroness Stern: I would like
to come back to maternity care. We have talked about it but there
may be a bit more to say in the light of this. We have been told
that hospitals are demanding payment and sending debt collectors
to visit pregnant women before or after they give birth. We have
been told this so I believe it, but I find it hard to believe.
Do you know of any cases where maternity treatment has been refused
to those who cannot pay and can you comment on the effects of
such actions on the health of the mothers and children? This is
different from the case we discussed earlier.
Dr Burnett: There are many other
cases; I just picked out one which did have an obvious very detrimental
effect on the health of both mother and baby. I also have someone
registered with me currently who I saw today, where not only is
the effect apparent in the fact that she delivered a low birth
weight baby but also now, because the mother cannot afford to
eat properly, she is breast-feeding but her milk supply is diminished
and the baby is not putting on the weight that we would expect.
That is a very graphic example. She is somebody who is able to
access healthcare but the other social aspects of her life are
not being properly supported, and we heard about those earlier.
If she was not able to access healthcare I think the effect on
the health of both her and her baby would be even more dramatic
than it is already. Those are some cases and I know that Karen
has others.
Ms McColl: At Project London we
have seen women who have been refused maternity care unless they
could pay a deposit in advance for their care, and the Refugee
Council in their recent report First Do No Harm also had
cases of pregnant women who had been refused care. Those are the
lucky women because they are the women who came to see us or who
came to the Refugee Council and then we were able to advocate
on their behalf and say, "Government policy is that the risks
are so high to mother and child that you really should not be
refusing care even if she cannot pay". They were the lucky
women and the worry is that this policy spreads by word of mouth
as well and that there are women who are too afraid to go forward
for any care. We have seen women who were so terrified by the
prospect of accruing a debt that they really did not want to go
back to having any care at all and we have had to persuade them
of the importance of having antenatal check-ups and assisted delivery.
It is a very concerning situation.
Dr Azad: Obviously, there is a
real HIV issue here because of the real public health success
there has been in the last three or four years in the HIV antenatal
screening which has reduced undiagnosed HIV, particularly amongst
pregnant women in the African community. At the moment women have
to pay a bill, if they fall into, as it were, the wrong immigration
categories, for the drugs needed to stop their unborn child getting
infected with HIV. As soon as I tell people this they find it
extraordinary and I certainly find it extraordinary and I question
the human rights issues there. We have real concerns both around
a possible decline in the level of antenatal HIV screening and
around a possible increase in mother-to-child transmission of
HIV. This is just one case that was rung into us two days ago,
to give you a little bit of detail because it illustrates the
problem so powerfully. This was a pregnant woman living with HIV
who was an Article 3 claimant but her claim was refused in December
2005. She continued to get HIV treatment from her clinic, as she
should, but when she went for an antenatal screen that part of
the hospital spoke to the overseas payment visitor and the next
thing she knew she got a letter telling her that she could not
enter the hospital either for maternity care or for HIV care unless
she paid up front for her treatment. The result of that was that
she disappeared from care for three to four weeks and her HIV
nurses were very worried, obviously, about her health and that
of her unborn child. She was found through voluntary sector organisations.
The HIV clinic wrote a counteracting letter to the other letter
from the trust saying, "You must come in and keep on getting
the HIV treatment you need to survive and for the good of your
baby". There was then an argument in the trust and the trust
eventually reluctantly accepted that she could continue her HIV
treatment for free but insisted that she would still have to pay
for her maternity care. Now the HIV clinic are arguing that they
should take out the HIV-related bit of the maternity charge. The
woman is terrified and has no money. This is a cruel charade.
The bottom line is that whatever bill she gets she will not be
able to pay and everyone knows that. Going back to what Angela
said earlier, so much time is being spent by healthcare workers
on what we know economically is a pointless exercise and we know
medically is a harmful exercise, and that is what I find distressing
about these sorts of cases that are coming to our attention.
Q93 Lord Judd: Does anyone cost this
in terms of what the administration spends on fighting these battles
internally?
Dr Azad: Some PCTs seem to realise
that actually there is no point spending so much time billing
people who have no resources. It comes back to the cost/benefit
argument, that we are charging people for very cost effective,
preventive interventions. Anti-retroviral therapy is one of the
most cost effective medical interventions there is. If we deny
them that cost effective intervention they will simply present
in Accident & Emergency and then in intensive care with greater
and greater frequency and in a matter of a couple of days cost
the NHS as much as a year's anti-retroviral treatment. The Government
really has not had an answer to that cost/benefit point and the
same must be said for the amount of staff time that is being spent
on these sorts of cases.
Q94 Baroness Stern: I would like
to know what you actually do when you are confronted with a hospital
taking such action and a person who clearly cannot pay and needs
to be helped. Do you ring someone up or do you go and stand outside
with a notice? What do you do?
Ms McColl: If I can answer for
Médécins du Monde, in terms of when people are being
refused secondary care, when it is maternity care it is more straightforward
because we can advocate very clearly on their behalf using the
Department of Health guidance to argue.
Q95 Baroness Stern: So you ring up?
Ms McColl: We argue. We accompany
the woman to her next appointment usually. We then have to refer
the woman to an agency that can help her with debt advice and
she can be supported through the process, which is usually terrifying
for her, of having that debt, knowing that she will never be able
to pay it or that it will take her a very long time. With some
cases of other essential secondary care we have not yet been able
to find a solution. We have some people who are very seriously
ill, who need hospital treatment, and we continue to advocate
on their behalf but it is very difficult.
Q96 Baroness Stern: At what level
do you advocate?
Ms McColl: At every level we can.
Q97 Lord Judd: Dr Burnett, you argue
that the right to the highest attainable standard of health under
Article 12 of the ICESCR should be incorporated into UK domestic
law. This obviously has resource implications. Have you made any
calculations as to what those resource implications would be?
Dr Burnett: The resource implications,
as we have heard, are likely not to exceed hugely the amount of
time spent in administering the current system. The change in
policy which the Government brought forward seems to have been
based on a hunch that medical tourism is present to a really excessive
degree. When we are talking about people who have failed in their
asylum claim, they are not medical tourists under any guise at
all. They do not come here simply to access medical care and we
would argue that, certainly for this group of people, the cost
implications are not huge. We are talking about people for whom
as individuals it is a very significant issue, but the financial
problems of the NHS are not due to the health requirements of
people who have failed in their claim. It is a very small drop
in the ocean. There is some work that has not been made public
as yet, so I would have to not give too much detail about it,
but what I would say is that I do not think there is anything
that would contradict what we are saying, that basically the exact
figures are not there. The Government has not done a well-thought-through
cost implication. They have just brought this policy in.
Q98 Lord Judd: Can I ask on that
whether, if the work to which you refer reaches a conclusion while
we are still undertaking the inquiry, you could take steps to
persuade those involved to let us have the outcome of that?
Dr Burnett: Yes, certainly.
Q99 Lord Judd: The second point is
that while you may argue that it is up to Government to make these
calculations, and while it is obvious that you are all heavily
burdened with your front-line work, do you not agree that if the
NGOs could produce some figures in terms of the things we have
been discussing this evening it could give tremendous ammunition
to the cause?
Dr Burnett: Yes, I certainly agree,
and I think that is why this piece of work was undertaken.
1 Footnote from witness: "Treat with respect:
HIV, Public Health and Immigration", Professor Brian Gazzard,
Dr Jane Anderson, Dr Jonathan Ainsworth, Dr Chris Wood-available
at www.ukcoalition.org Back
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