Wanted to look at health charging not just as an isolated policy but in a historical and political context. What is new about it as policy? How does it link with other social security policy in relation to migrants? Strength of human rights legislation is that it codifies human rights. However, one consequence is that migrants’ rights are often seen within a legal rather than a political context. Also want to demonstrate impact of current regs. on both documented and undocument migrants, because anecdotal evidence and few studies investigating this area show a degree of confusion about entitlements among health care administrators and professionals. Important point is that regulations make situation more difficult for all migrants.
Health policy - Paper came out of discussions about changes to NHS entitlements for asylum seekers introduced in 2004. Proposed in 2003 and consultation on primary care charging. Earlier version of paper written with Ros Bragg but developed a little chronologically. 2010 consultation- Review of Access to the NHS by foreign nationals Immigration enforcement policy - Looked at policy basis for charging in relation to broader policy changes via “ Enforcing the Rules ” Other policy documents about immigration came out regularly during the Labour Govt. Enforcing the Rules had particular implications for health provision, especially involvement of civil society in immigration control - hospitals, universities, employers, DVLA More recent documents 2010 Protecting our Border, Protecting the Public and consultation document about penalties for NHS debt Concern about development and political manipulation of hostile climate to asylum seekers, especially re. health tourism.
Brief history Restrictions on access to services don’t just pertain to NHS. Residence criteria pertained to historic poor laws re. people’s entitlement to relief where. Elizabethan England “Since each parish was required to look after its own poor, there evolved a national pattern of dispute and litigation over where responsibility lay for individual paupers whose real place of residence was doubtful. At the heart of all anti-vagrancy legislation from the 14th Century onwards had been the desire to return wanderers to their proper and rightful parish…Overseers, conscious that ratepayers wished to keep poor rates down, did all they could to prevent paupers becoming chargeable on their particular parish and the courts were full of rival overseers disputing settlement.” Fraser Restrictions existed since 1905 Aliens Act; now include concept of “No Recourse to Public Funds which restricts access to housing, benefits, women’s refuges. 1962 Commonwealth Immigrants Act Instructions to Immigration Officers said that dependants would be refused admission if could not prove that some relative in the UK would support them. 1982 implementation of charging in the wake of a new Nationality Act in 1981 which redefined British citizenship
We explored term HT because it became so important in the discourse around changing the charging regulations. In 2002 HT only referred to in parliament in relation to market opportunities. Suddenly linked to failed AS in 2003. HT also seen as ‘legitimate’ money spinner in countries like India and Cuba. 2003 regs. introduced by reference to “ considerable public concern about abuse of the NHS by ‘ health tourists ’ . Health tourism quickly became a euphemism for “ abuse ” of NHS by FAS. The government freely admitted that it had never collected data on the numbers of ‘ health tourists ’ who used the NHS
Liam Fox 1st to use the term in this sense. But quickly followed by Labour ministers. No evidence given for claims in Fox’s statement. Note in B. Hughes’ quotation - elision from “exploitation by HTs” to “anyone with no legal basis”. Clearly not necessarily HTs at all. Shift in discourse in the face of lots of opposition. Consultation on access and charging published on 26 Feb after years of delay. Admission that “ most overseas visitors who seek the help of the NHS do not set out to abuse the NHS as health tourists. Similarly, most unlawfully resident migrants are not health tourists – they come to the UK for other reasons”. Also that don’t have detailed data on the scale of health tourism.
Shift in Health services ’ responsibilities from the earlier 1989 regulations which merely expected the relevant Health Authority to make “ reasonable ” enquiries as to a person ’ s liability to charges “ including the state of health of that overseas visitor ” (NHS 1989). Now statutory role of Hospital Trusts to determine the eligibility of patients to free care ( NHS 2004:5). What has alarmed many people, including health workers at all levels, as well as those working with migrants, is both the non-clinical criteria for eligibility that are now applied, but also the close and deliberate integration of this process with attempts to curb “ illegal ” immigration. Thus responsibility for ensuring that patients who are not “ ordinarily resident ” in the UK are identified has now been devolved to agencies not normally charged with law enforcement. This procedure forms an explicit part of the government ’ s new enforcement policy as set out in the Home Office ’ s strategy document Enforcing the Rules.
This strategy sought to justify a more open policy towards migrant workers at the expense of others seen as ‘illegal’. To do this it sought ways increasingly to criminalise the undocumented and to restrict their ‘privileges’, many of which, including the rights to shelter and healthcare, are regarded by many as basic human rights. It goes further still by proposing the development of mechanisms to involve civil society agencies such as health and other public service providers, and private agencies such as banks to access information and themselves determine whether or not “migrants are here legally and entitled to services” as a means of applying sanctions to those living ‘illegally’ (Home Office 2007:5). A more recent policy paper Protecting our Border, Protecting the Public shifts discourse even more to criminality linking drug smuggling,tobacco smuggling, arms smuggling to Iran, preventing fraudulent access to UK benefits and services including health tourism. A current consultation about whether NHS debtors should be barred from re-entry to the UK or denied or delayed citizenship was published in the same month. A main concern is the tight link between the HO and NHS trusts ( Refusing entry or stay to NHS debtors) . But NB in the consultation on debt the only reference to actual losses incurred by unpaid debts by overseas visitors is £5m, or approx. 0.005% (5/100,000) of NHS budget of approx. £10 bn. NB Cost of developing policy and enforcing it may well exceed loss to NHS. “Indeed one suspects that often more time and money were spent on litigation than the sustenance of the pauper would have involved” (Fraser,re.Elizabethan Poor Law). It is these policies that helps us understand that restrictions on access are not about cost but about extending/transforming border controls into internal controls. The strategy’s a dditional goal is to drive people away by denying them basic services.
Inappropriate refusal of types of care, often maternity care which is always exempt. (Ros to discuss) Newham study showed that maternity services were being targeted. Refugee Council report discusses women giving birth at home unaided. GP discretion is major barrier to treatment access since GPs are gatekeepers within NHS system. Illustrated by example of Roma woman from Refugee Council study. J is a Roma woman with diabetes and high blood pressure. She was referred to [the Refugee Council] after being turned away by every local GP in her area. When she went to her local Accident and Emergency department, they too turned her away, saying her condition wasn ’ t life threatening or an emergency, that if she wanted healthcare, she would have to pay. J is destitute. (Kelley & Stevenson 2006). An African male failed asylum seeker, who is a diabetic on insulin injections twice a day and had run out of insulin. The receptionist at a GP surgery refused to allow him to see a GP....He attended A&E where he was prescribed insulin as an immediately necessary treatment. These examples shows contradictory patterns - the effect of combination of discretion of GP care, and emergency criteria of A&E care can deny treatment to people who need care but appear not to be entitled. Easy to see that the situation could become life-threatening (and more expensive). PTO
Public health - e.g. concerns re. delayed detection of TB or HIV leading to failure to treat, undermining of PH goals e.g. mass childhood immunisation, reducing maternal and infant mortality, & TB reduction Indiv. health - evidence of continuing physical and mental health problems among refugees and asylum seekers from BMA, Ref. Council and other sources Barriers to treatment access as described e.g. unattended home delivery, refusal of post-natal follow up, denial of insulin and cancer treatment. Non-use of interpreters, effect of discretion on GP registration of undocumented migrants Contradictory outcomes in health policy e.g. increased & use of emergency services while policy to reduce inappropriate use of such services, poorer maternal health and increased risks to public health The policy also risks undermining other social policies such as race equality, refugee integration and programmes to integrate skilled migrant workers, and is in danger of creating a more intolerant and unequal society.
Healthcare and Immigration Policy in the UK: Health Services and Immigration Control
Health care and immigration policy in the UK: Health services and immigration control Rayah Feldman London South Bank University
Aim of paper <ul><li>to contextualise changes in regulations historically and in terms of contemporary political discourse </li></ul><ul><li>to consider impact of current regulations </li></ul>
Context <ul><li>Changing policy on health access </li></ul><ul><li>New approaches to enforcing immigration controls </li></ul><ul><li>Hostile social climate to migrants </li></ul>
Welfare, health and foreigners <ul><li>Historic exclusion of people from outside parish from poor relief </li></ul><ul><li>NHS Act 1949 - included powers to allow Minister to impose charges for people not “ ordinarily resident” in UK </li></ul><ul><li>Charging of people not “ ordinarily resident” formally implemented 1982 </li></ul>
“ Health Tourism” <ul><li>Pre 2002 never mentioned in parliament </li></ul><ul><li>2003 linked to exploitation of NHS by “failed” asylum seekers </li></ul><ul><li>Becomes justification for revising charging regulations </li></ul><ul><li>No data ever collected on numbers of “health tourists” using NHS </li></ul>
<ul><li>“ the NHS is becoming the health equivalent of Disneyland for tourists… Hundreds of thousands of people who have failed the asylum process are trying to use our healthcare system. This means British citizens already waiting for treatment have to wait longer” (Liam Fox Shadow Health Secretary 2003) </li></ul><ul><li>“ proposals to amend these (Overseas Visitors) Regulations (are intended) to remove certain loopholes that have been exploited by health tourists. In particular anyone who has no legal basis to remain in the United Kingdom will be liable to be charged for NHS treatment. (Beverley Hughes Under-Secretary of State Home Office, 2004) </li></ul><ul><li>Health tourism: A term used to describe individuals that come to the UK to use the NHS for medical services without payment ( Protecting our Border, Protecting the Public , 2010 ) </li></ul>
“ Enforcing the Rules” <ul><li>1989 NHS charging regulations required “reasonable” enquiries into liability for charging </li></ul><ul><li>2004 regulations - NHS Hospital Trusts have statutory role to determine eligibility of patients to free care </li></ul><ul><li>“ Enforcing the Rules” Home Office 2007 - devolution of responsibility for identifying people not legally entitled to services in order to apply sanctions to those living in UK illegally </li></ul>
<ul><li>“ Those not prioritised for removal … .. should be denied the benefits and privileges of life in the UK and experience an increasingly uncomfortable environment so that they elect to leave. ” ( Enforcing the Rules: A strategy to ensure and enforce compliance with our immigration laws Home Office March 2007) </li></ul>
Impact of current policies <ul><li>Confusion over entitlement </li></ul><ul><li>Barriers to treatment access </li></ul><ul><li>Public health </li></ul><ul><li>Individual health </li></ul><ul><li>Contradictions in health policy </li></ul><ul><li>Undermining integration strategies </li></ul>
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