Safe Surgeries in Central London Improving healthcare access for vulnerable migrants [Picture: DOTW clinic in Calais, 2015]

Patient registration in Central London Of 156 attempts by our caseworkers to register patients in Westminster in 2016-2018, 22% were wrongly refused. The reasons for refusal were: Lack of paperwork (proof of ID/address) Immigration status Gatekeeping 94% of service users had experienced difficulties accessing healthcare, and 89% were not registered with a GP when they came to our clinic We ask all service users why they had not been able to access the NHS. 53% responded that they did not try to access the NHS because of perceived barriers. Of those that tried, most cited psychosocial barriers, such as admin difficulties (22%), lack of understanding of how to access the NHS (16%), language barriers (14%) and refusal by healthcare admin staff (14%). 2% cited economic barriers (asked to pay in advance and couldn’t afford treatment). 11% of patients told us they did not access NHS services because they feared arrest if they did. This figure is consistent with previous years (12% in 2015, 11% in 2014). 23% said that they limited their movements for fear of being arrested. (data from 2016)

Nationality and immigration status are not relevant to GP registration and do not have to be reported: “anybody in England may register and consult with a GP without charge”. Lack of proof of address/ID are not reasonable grounds to refuse registration. Source: Primary Medical Care Policy and Guidance Manual (NHS England, 2017)

Upfront NHS charging: implications for at-risk adults [Picture: DOTW clinic in London, 2015] Upfront NHS charging: implications for at-risk adults © Doctors of the World UK 2018

CHARGING IN SECONDARY CARE Chargeability in secondary care depends on immigration status. Undocumented migrants (incl. refused asylum seekers) are charged. Charges must be paid before treatment, which can be withheld if a patient can’t pay. “Urgent or immediately necessary” treatment to be provided regardless of ability to pay (charged for after). Some groups are exempt, incl.: Refugees and asylum seekers; Survivors of sexual or domestic violence, FGM, torture, only for treatment related to experience of violence; Survivors of MDS who’ve been referred to NRM with reasonable grounds. [Picture: DOTW clinic in London, 2015] Let’s turn to the complex world of secondary care entitlement and charging Non-EEA migrants pay a visa surcharge This is an overview We will look in more detail at what each section means e.g. £6,500 for uncomplicated delivery & ANC. Secondary care refers to services provided by medical specialists who generally do not have the first contact with a patient.  You are usually referred to secondary care by a primary care provider such as a GP.

NHS as a safe space? Deterrence: Patients fear ID checks & unaffordable bills – both trigger data- sharing with the Home Office. 2. Gatekeeping by admin staff Reception staff delay or deny access to doctor due to ID checking bureaucracy. 3. Incorrect assessments of urgency & exemptions Clinicians or OVMs wrongly apply definitions & deny care. Picture: DOTW service user shows her NHS antenatal bill, 2015] © Doctors of the World UK 2018

“I don’t have money – I don’t work, I don’t have money to pay them “I don’t have money – I don’t work, I don’t have money to pay them. That makes me too stressed, because all the time I receive letter I have to pay this bill.” “I don’t want this asthma attack because I don’t know what I’ll find at the hospital. I’m living in fear... I feel I need a case worker with me.” Esther, a stateless woman in Nottingham, living in the UK since 2000. A woman seeking asylum in Nottingham. “I never received any maternity care... I was so scared I didn’t ask about pregnancy care. Being part of the system would enable charges to be brought against me, and I also was afraid about deportation.” A woman in London who had been refused asylum [Picture: DOTW clinic in London, 2015] To explain healthcare entitlement and the barriers that patients face when accessing the NHS, we will use the case study of Miriam Miriam came to DOTW in 2015 Read from slide Source: Equality & Human Rights Commission. The lived experiences of access to healthcare for people seeking and refused asylum. 2018. © Doctors of the World UK 2018

What does good practice look like? Let’s talk about primary care… https://www.england.nhs.uk/publication/primary-medical-care-policy-and-guidance-manual-pgm/

Safe Surgeries network Our aim is to improve GP registration practices nationally, and bring them in line with NHS guidance. Ask your practice to sign up now: www.bit.ly/newsafesurgery Invoicing can be delayed, if appropriate, until delivery. Scope for advocacy to OVM. Encourage her to engage with treatment. Understand her fear of bills and the Home Office. Always ask about violence. Know which services are exempt from charges. If relevant, raise in your referral letter that: treatment is ‘urgent’ or ‘immediately necessary’; the patient falls into an ‘exempt’ group; The answers on the slides are just suggestions. Participants may come up with other ideas.

175+ Safe Surgeries nationwide committed to taking steps to tackle the barriers to healthcare faced by migrants.