Healthcare charging and common barriers to accessing healthcare for refugees and people seeking asylum What’s the current situation? Common barriers to accessing healthcare for refugees and people seeking asylum New charging regime: What’s the effect on refugees and people seeking asylum? Plus data-sharing agreement and new GMS1 form. What can you do? Best practice and sources of information Estelle Worthington, Asylum Matters

Common barriers to accessing healthcare for refugees and people seeking asylum Difficulties with GP registration Frontline staff questioning their entitlement Language barriers and communication issues No-choice dispersal and frequent moves Having been charged for care in the past or fear of charging in the future Fear of breaches of patient confidentiality with Home Office Lack of awareness about how NHS works Consequences of barriers to accessing healthcare Rise in health inequalities. Failure to identify mental health issues and introduce support. Interrupted treatment = lack of access to essential medication for ongoing conditions. Delayed treatment = higher cost of care and more pressure on emergency services. Conditions become more complicated and expensive to treat. Longer stays in hospital. Delayed access to ante-natal care = complications and higher death rates. Absence of early diagnosis of communicable diseases, leading to possible public health risks.

Who is entitled to what? Refugees: entitled to free healthcare at all levels of care. People seeking asylum: entitled to free healthcare at all levels of care (whilst their application for asylum is still being considered or any appeal is pending).   Refused asylum seekers: now chargeable for many services. However, charges do not apply to those receiving Home Office Section 4 support, or those supported by the local authority under the Care Act 2014.   BUT, regardless of the patient’s chargeable status, all immediately necessary and urgent treatment must be provided, though the patient may later be charged.

NHS Charging Regulations New rules came into force on 23 October 2017 that: Extend charging into community healthcare services Includes community midwifery, community mental health services, termination of pregnancy services, district nursing, support groups, advocacy services, drug and alcohol services, and specialist services for homeless people and asylum seekers. Excludes health visitors and school nurses. Introduce up-front charging If a patient cannot prove that they are entitled to free care, they will receive an estimated bill for their treatment, and treatment will be withheld until the patient pays in full, unless it is deemed ‘urgent’ or ‘immediately necessary.’ Home Office will be notified of any unpaid bills over £500. Context - Part of Government’s ‘hostile environment’ agenda. - Explain concerns expressed by medical professionals: Open letter to Jeremy Hunt (signed by 193 organisations – many of them medical bodies – and 880 individuals, including many doctors and nurses). Media exposure. House of Lords debate. Advocacy has led to 2 outcomes: i. Health visitors and school nurses being removed from list of ‘relevant services’ that have to check patient eligibility. ii. Formal review of regulations and the impact on vulnerable groups (upcoming). - There were already many barriers to healthcare in place for vulnerable RAS before the regulations, and the latest charging rules are set to exacerbate this. Our concerns: - Regulations to enable extension of charging were laid without evaluation of their impact on health outcomes and health inequalities and without sufficient Parliamentary scrutiny or public consultation. - Unworkable and costly to the NHS. Many vulnerable migrants (especially refused asylum seekers) will have no means of paying bills. - Will lead to increased patient waiting times. - Undermines relationships of trust between patients and medical professionals. - Risk of racial profiling to identify chargeable patients. - Vulnerable people deterred from accessing care. - Widespread confusion over entitlements will exacerbate current health inequalities. - Life-saving care could be withheld.

Some exemptions apply… Charges do not apply to those who have paid the health surcharge, those with an EHIC card or equivalent. Overseas visitors may also qualify for an exemption from charging on a number of other grounds. See DH guidance for full details. ‘Chargeable’ patients won’t be charged for: GP services; A&E, including walk-in centres, minor injuries units or urgent care centres (up until the point when patient admitted); family planning services (does not include termination of pregnancy); diagnosis and treatment of specified infectious diseases and sexually transmitted infections; palliative care services provided by a registered palliative care charity or a community interest company; services that are provided as part of the NHS111 telephone advice line; treatment required for a physical or mental condition caused by: torture; FGM; domestic violence; or sexual violence. See Guidance for full list of exemptions: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/666031/UPDATED_Guidance_to_Charging_Regulations_post_23_October.pdf Main exemptions to highlight: Those who have paid the health surcharge (usually applied to people who will be in the UK for 6 months or more). Overseas visitors who reside in an EEA state (including non-EEA nationals) may be insured under the public healthcare insurance system in their resident member state. They will have, or should be entitled to hold, a European Health Insurance Card (EHIC) or Provisional Replacement Certificate (PRC) from the EEA state in which they are insured. Child looked after by LA (but not families cared for under Section 17 of Children’s Act). Victims, and suspected victims, of modern slavery. An overseas visitor who has been granted leave to enter the UK outside the immigration rules, in whose case the Secretary of State for Health determines there to be exceptional humanitarian reasons to provide a free course of treatment. Anyone receiving compulsory treatment under a court order or who is detained in an NHS hospital or deprived of their liberty. Prisoners and immigration detainees.

Other developments preventing refugees and people seeking asylum getting the care they need Data-Sharing Memorandum of Understanding has been in place between the Home Office and NHS Digital since 1st January 2017. Allows the Home Office enforcement staff to access patient registration data, including full name, date of birth, gender, last known address and date of NHS registration of patients. The Home Office made 8,127 requests for data in the first 11 months of 2016 alone. This led to 5,854 people being traced by immigration teams. Changes to GMS1 Form Now includes a ‘supplementary questions’ section to determine a patient’s eligibility for free healthcare. This is contributing to confusion over who is entitled to register with a GP/ who qualifies for free services. New GMS1 form - Runs counter to NHS England guidance on GP registration. See ‘How to register with a doctor (GP), Refugees and Asylum Seekers’ leaflet, NHS England: https://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Documents/how-to-register-with-a-gp-assylum-seeker-and-refugees.pdf - The form does not make it clear that it is not mandatory that practices fill in the new GMS1 form supplementary questions. - New NHS England Guidance on GP registration. P144 onwards deals with ‘Who can register for primary care services?’ https://www.england.nhs.uk/publication/primary-medical-care-policy-and-guidance-manual-pgm/ - If problems with GP registration persist, contact equalities lead at CCG for assistance.

How can we change the story?

Best practice examples… Health & Wellbeing Boards to develop local strategy for refugees & asylum seekers Commission specialist services for refugees and people seeking asylum Allow for longer appointment times Provide face to face interpreting Training for all staff Invest in educating patients about how to navigate NHS and stay healthy Use NHS England Patient Registration Guidance and promote clear message about duty to register, regardless of immigration status Promote Doctors of the World ‘Safe Surgeries Toolkit’ to prevent patient data being shared. Advocate for patients and use discretion to provide free treatment wherever possible Refer patients facing charging to relevant advice lines: Doctors of the World: 0207 515 7534 Maternity Action: 0808 802 0029 Useful information/ guidance: How to register with a doctor (GP), Refugees and Asylum Seekers leaflet, NHS England: https://www.nhs.uk/NHSEngland/AboutNHSservices/doctors/Documents/how-to-register-with-a-gp-assylum-seeker-and-refugees.pdf Healthcare Needs and Pregnancy Dispersal Guidance v3.0, UK Visas and Immigration: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/496911/new_Healthcare_Needs_and_Pregnancy_Dispersal_Policy_EXTERNAL_v3_0.pdf Safe Surgeries Toolkit, Doctors of the World: https://www.doctorsoftheworld.org.uk/Handlers/Download.ashx?IDMF=06897b0f-6a03-493f-a288-f9ddce44cbcc A “Champion” within each service or GP practice Focus on mental health

Stay in touch with Asylum Matters! Estelle Worthington: North West Campaigns Project Manager estelle@asylummatters.org | 07557 983 264 | @AsylumMatters