[Picture: DOTW clinic in Calais, 2015] DOCTORS OF THE WORLD UK

MÉDECINS DU MONDE International organisation providing healthcare for excluded people all over the world. International programmes For example, Ebola response in Sierra Leone, Hurricane Mathew in Haiti, healthcare along refugee routes in Europe [Picture: MdM Ebola response in Sierra Leone, 2014] DOTW UK is part of the MdM network An international organisation that provides healthcare for exculded people across the world. Examples of international programmes are Ebola response in Sierra Leone, Hurricane Mathew in Haiti, healthcare along refugee routes in Europe

DOCTORS OF THE WORLD IN THE UK A drop in clinics in London and Brighton: Short-term medical care provided by volunteer GPs and nurses GP registration advocacy service 1,601 patients seen in 2015.  [Picture: DOTW clinic in London] MdM also run domestic programmes in our own countries. The UK domestic programme is the DOTW clinics in London and Brighton A service for people who cannot access the NHS Our service includes: short term medical care, GP registration advocacy In 2015 we saw 1605 patients

SERVICE USERS Who uses DOTW’s services? Mainly vulnerable migrants: 58% undocumented migrants, 16% asylum seekers. From 77 different countries: top countries were Philippines, Bangladesh, India, Uganda and China. On average have been living in the UK for 6.5 years 77% living below the poverty line 36% homeless (either rough sleeping on vulnerably housed)

PRIMARY CARE ENTITLEMENT “Everyone in England is entitled to free primary care regardless of nationality or immigration status.”NHS Standard Operating Principles on GP Registration “Inability by a patient to provide proof of address/ ID would not be considered reasonable grounds to refuse to register a patient or withhold appointments”NHS Standard Operating Principles on GP Registration [Picture: DOTW clinic in London, 2015] The key document on primary care entitlement is NHS England Standard Operating Principles on GP Registration It says: Everyone in England is entitled to free primary care regardless of nationality or immigration status.” It also says: “Inability by a patient to provide proof of address/ ID would not be considered reasonable grounds to refuse to register a patient or withhold appointments” (The policy is the same in Scotland, Wales and NI, just no document that summarises it like this)

PRIMARY HEALTHCARE: BARRIERS When DOTW service users approached GPs they faced the following barriers: [Picture: DOTW clinic in London] DOTW ask all patients why they could / did not access the NHS 52% – didn’t even try – believed they were not entitled to access the NHS 29% - administrative difficulties – this means they didn’t have proof of address/ID so were refused registration 17% - didn’t understand how to access NHS - i.e. that you have to be registered with a GP (data from 2015)

ENTITLEMENT TO SECONDARY CARE OVERVIEW General rule: refused asylum seekers and undocumented migrants are charged for secondary care Charges are 150% NHS tariff and must be paid before treatment (as of April 2017) Some services are exempt from charges “Urgent or immediately necessary” treatment will be provided regardless of ability to pay (upfront payment not required) [Picture: DOTW clinic in London, 2015] Secondary care entitlement is very complicated This is an overview We will look in more detail at what each section means

HEALTHCARE ENTITLEMENT IN THE UK: EVERYONE IN THE UK IS ENTITLED TO FREE PRIMARY CARE SECONDARY CARE EXEMPTIONS A&E, certain infectious diseases, family planning. Asylum seekers, refugees, those granted humanitarian protection and some refused asylum seekers (receiving S.4/95 support). Victims of trafficking or modern day slavery. Victims of violence: domestic violence, sexual violence, torture and FGM)- for treatment relating to their vulnerability only. Children under the care of a local authority and treatment under the Mental Health Act. IMMEDIATELY NECESSARY AND URGENT CARE Must be given regardless of someone’s ability to pay. Patients should not be discouraged from accessing it. Patients should not have their treatment delayed to determine chargeability. It must be provided and then billed afterwards. Primary care Everyone in the UK is entitled to free primary care. NHS England principles on GP registration say: Immigration status is not relevant Lack of proof of address or ID should not prevent GP registration and appointments [Picture: DOTW clinic in London, 2015]

ENTITLEMENT TO SECONDARY CARE Immediately necessary Urgent or immediately necessary care Must be given regardless of ability to pay. Treatment should not be withheld pending upfront payment. Only clinicians can make this assessment. Maternity services are “immediately necessary” inc. ANC. Immediately necessary Life saving, will prevent a condition becoming life-threatening or will prevent permanent serious damage. Urgent Cannot wait until they can return to their country of residence. Should take into account pain, disability, and the risk of the delay exacerbating their condition. For undocumented migrants assume may not be able to return within 6 months. Care that is ‘urgent or immediately necessary’ will not be denied. This does not mean it is free, patient does not have to pay in advance. Only a clinician can make this decision. Maternity services should always be treated as ‘immediately necessary’. These are the definitions. Note: Should take into account pain, disability, and the risk of the delay exacerbating their condition. Note: undocumented migrants assume may not be able to return within 6 months.

SECONDARY CARE: BARRIERS Patients fear bills they cannot pay so do not access treatment. Immigration status checks make patients fear immigration enforcement (held in detention and deportation) Hospitals refusing ‘urgent or immediately necessary treatment’ until patient pays in advance Hospitals and debt collection agencies aggressively chasing destitute patients for money. Hospitals billing or denying care to exempt groups. Picture: DOTW service user shows her NHS antenatal bill, 2015] DOTW see the following barriers stop patients accessing the secondary care they are entitled to.

SECONDARY CARE DOES THE NHS SHARE INFORMATION WITH THE HOME OFFICE? Hospital bills often threaten to report patients to the Home Office, which deter patients from accessing healthcare. Hospitals notify the Home Office of bills £500+ and outstanding for over 2 months. 2017: A Memorandum of Understanding between the Home Office and NHS Digital requiring NHSD to share non-clinical patient information – i.e. patient address – for immigration enforcement. Picture: DOTW service user shows her NHS antenatal bill, 2015] Miriam’s letter made reference to the Home Office. If Miriam is reported to the Home Office they may carry out immigration enforcement (held in detention centre, deported to Eritrea) Many undocumented migrants and refused asylum seekers fear the Home Office Does the NHS share information with the Home Office? Yes.

Family Clinic - Why? WOMEN’S & CHILDREN’S SERVICE STARTED IN OCTOBER 2014 DUE TO THE NEED FOR INCREASED SUPPORT FOR PREGNANT WOMEN AND FAMILIES WITH CHILDREN UNDER 18 7.5% of all service users (132) in 2016 were pregnant Studies have pointed to a higher prevalence of unmet health needs among migrant children There is also considerable evidence that migrant women have disproportionately poor pregnancy outcomes compared to the UK-born population. 1 IOM. Maternal and Child Healthcare for Immigrant Populations. Background Paper. Brussels: International Organization for Migration, 2009 2 M. Knight, D.Tuffnell, S.Kenyon, J. Shakespeare, et al. (Eds.) EMBRACE, 2015, Saving Lives, Improving Mothers’ Care: Surveillance of maternal deaths in the UK 2011-13 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-13, National Perinatal Epidemiology Unit

EXPERIENCE OF PREGNANT MIGRANT WOMEN - UK MATERNITY SURVEY Survey of 87 pregnant women that DOTW seen between Jan 2013-June 2014 34% access care after 20 week2s 50% had 5 or less Antenatal appointments 2 neonatal deaths - mothers billed for care BARRIERS TO ANTENATAL CARE Fear of debt Moving – loss to follow up Fear of detention Unknown appointment times and places Ref: - Shortall C, McMorran, J., Taylor, K., Traianou, A., Garcia de Frutos, M., Jones, L. and Murwill, P. Experiences of Pregnant Migrant Women receiving Ante/Peri and Postnatal Care in the UK: A Doctors of the World Report on the Experiences of attendees at their London Drop-In Clinic. 2014. Available from: https://www.researchgate.net/publication/274318976_Experiences_of_Pregnant_Migrant_Women_receiving_AntePeri_and_Postnatal_Care_in_the_UK_A_Doctors_of_the_World_Report_on_the_Experiences_of_attendees_at_their_London_Drop-In_Clinic [accessed Jul 29, 2015].

Family Clinic – What? THREE ARMS OF THE INTERVENTION A twice monthly Clinic – Primary Healthcare with enhanced Reproductive Health, Child Health and Mental Health and Psychosocial Support components Case work and fostering new links Data collection, needs assessment and advocacy Tuesdays 12pm-6pm for pregnant women Helpline between 10am - 12pm Monday to Friday Volunteer case work team Monday to Friday

DOTW’S POLICY RECOMMENDATIONS Full access to free primary, emergency and other essential care for everyone living in the UK. Exemptions from healthcare charges for children and pregnant women living in the UK. NHS information should not be shared with the Home Office, accessing treatment should never be used as a means of immigration enforcement. Health professionals should be supported to take care of all patients regardless of their administrative status.

THANK YOU AMILLER@DOCTORSOFTHEWORLD.ORG.UK