In the UK and across Europe, immigration and health policies have become increasingly intertwined. The UK Department of Health is currently proposing to introduce charges for overseas visitors and migrants to access Accident and Emergency (A&E) and some GP services despite evidence of potential harm to public health and limited if any economic benefit.

This proposal comes after the highly controversial 2014 Immigration Act that introduced a health surcharge of £150-200 for all non-EAA nationals travelling to the UK or 150% of the usual charge for hospital treatment. The Act was part of a deliberate Government strategy to create a “hostile environment” for undocumented migrants living in the UK1. There has been a significant backlash with the UN saying the Act was much too harsh in a climate already hostile to migrants 2. NHS England and Public Health England had also raised serious concerns about the impact of charging proposals on public health and worsening health inequalities as far back as 2013. Research has shown these concerns are not unfounded, with the current proposals likely to heavily impact undocumented migrants living without legal status in the UK, including vulnerable groups such as pregnant women and parents with children3 4 5 6.

The evidence that accessible primary care for everyone reduces inequalities and improves the health of the general population is irrefutable7 and is the cornerstone of many international laws and treaties. The Alma-Ata Declaration of 1978 firmly established the vital role of primary health care in attaining the goal of ‘Health for All’, reaffirming health as a human right and necessary for economic and social development. It specifically states “all countries should cooperate in a spirit of partnership and service to ensure primary health care for all people since the attainment of health by people in any one country directly concerns and benefits every other country.” Additionally, the UN International Covenant on Economic, Social and Cultural Rights to which the UK was signed and ratified in 1976, sets out the right to the highest attainable standard of health for everyone and for which access to all necessary health care services is essential.

In the UK, despite the ostensible NHS aim of universal health coverage, health inequalities continue to persist and certain populations face barriers in accessing health services they are entitled to. Doctors of the World’s volunteer-led clinic in east London saw more than 1500 vulnerable people last year who were experiencing difficulties accessing basic healthcare despite being fully entitled to do so. The majority are undocumented migrants who have been living in the UK for an average of six years and who have not received any healthcare since arriving in the UK8. Many have chronic conditions such as hypertension and diabetes that have not been previously treated, with some experiencing avoidable severe complications necessitating more costly emergency care.

Immigration checks and charges
The proposed legislation to extend health care charges was included in the 2016 Queen’s Speech9 and the Department of Health has now consulted on this. The government has committed to keep GP and nurse consultations free for all but only exempt specific vulnerable groups such as those subjected to sexual and domestic violence, torture and human trafficking from charging in other areas of primary care. They have also pledged to ensure that immediately necessary treatment continues to always be provided and to provide clear guidance about entitlements to NHS staff. However, there is evidence that staff working in healthcare settings remain confused about regulations concerning eligibility particularly regarding GP registration10. A report published by Doctors of the World UK found that of 849 attempts to register clinic attendees with a GP in 2015, 39% were initially wrongly refused due to lack of ID, proof of address or because of immigration status11. Previous equality assessments have also identified the risk of discrimination of minority groups through application of racial (including linguistic) profiling by staff12. There is no monitoring system in place to see whether this has continued or worsened during implementation of the first stages of the governments cost recovery programme and The Race Equality Foundation has stressed that the requirement to prove eligibility in order to access healthcare is likely to lead to profiling which will disproportionately impact BME communities. The proposal to introduce eligibility checks and charging into primary care services is unlikely to be cost-effective, workable or efficient and may deter vulnerable groups from accessing primary care altogether.
One of the stated benefits of asking about eligibility in primary care is to identify chargeable patients before they access secondary care. However the governments own impact assessment reports the value of identifying secondary care chargeable visitors and non-EEA patients in primary care is 'negligible' and a small value (£200,000 per year) could come from patients with an EHIC card13. This would put undue expectation and pressure on primary care resources for relatively little benefit.

All services delivered within the remit of a GP practice, other than a GP or nurse consultation, are being considered to carry a charge. This would include simple investigations such as blood tests that are essential for monitoring chronic diseases like diabetes. The impact assessment could not quantify the savings to be gained from charging for these primary care services and described that it was likely to make up a small proportion of costs in primary care. This reflects the complexity in unpicking diagnostic tests from general primary care and without an estimate of the likely savings it cannot be demonstrated that it is cost effective to proceed. It is also not clear how tests required to determine whether care is immediately necessary or urgent would be managed or if simple measures such as immunisations would be charged for.

The purpose of primary care is to assess the broadest range of health needs and identify how best to meet them. If someone experiences going to a GP but not being able to have diagnostic tests or prescription medication it is likely the value of primary care in prevention and early intervention will be highly limited. Primary care services are at the frontline of early detection of diseases that would, if untreated, worsen or become more complicated to treat and require more costly secondary or emergency care. A Doctors of the World study on type 2 diabetes showed that providing irregular migrants with entitlement to primary healthcare would lead to earlier diagnosis and prevent diabetes-related complications, saving the NHS at least £1.2 million and 832 years of healthy living (quality-adjusted life years)14. Another study published in September 2015 found that providing access to regular preventative healthcare for migrants in an irregular situation would also be cost-saving for governments15. Restricting access to primary care will increase pressure on other parts of the NHS that already struggle with demand and are far more expensive to run.
The consultation and impact assessment did not describe how primary care would be able to maintain up to date information on a patient's chargeable status over time but it did describe the requirement for a new IT system which has not yet been scoped. Given the very limited cost savings described, the current pressures already existing in primary care and the track record of introducing new IT projects in the NHS it is difficult to see how implementation of a new IT system would be cost effective.

Removing the last safety-net
The proposals also include charging for care received in A&E departments, ambulance services and for non-NHS out of hospital care that would include many urgent and out of hours GP providers. These are health care settings in which those who become acutely unwell are provided with essential and often life-saving treatment, and for some is the only health care that can be easily accessed. Trying to assess entitlement in A&E and whether treatment is urgent or immediately necessary is likely to increase delays, put lives at risk, and may lead to people being wrongly charged or discriminated against as staff seek to make quick decisions because of resource pressures. There is also a risk that follow-up checks and the pursuit of charges levied will further waste NHS resources, particularly as many people will be either wrongly charged or unable to pay.

In the rest of Europe, healthcare entitlements for undocumented migrants vary with the existence of charges often alongside insurance based systems16. However, most countries offer access to emergency care and all care to pregnant women and children that is exempt from charging, with many countries setting up alternative funds and services to provide care to excluded groups. In countries that implemented charges for undocumented migrants for emergency and essential care (Sweden and Spain), restrictive policies were found to be unworkable and caused significant health risks and were subsequently reversed. Despite this, undocumented migrants in these countries continue to be charged or are denied access to health care due to confusion around entitlements16.

Implications for the future
The proposal to introduce eligibility checks and charging into primary and emergency care has not been proven to be cost-effective or efficient, risks discrimination and will likely deter vulnerable groups from accessing these services altogether. The impact assessment makes the assumption that the measures described by the Department of Health to protect vulnerable groups are sufficient. Our evidence shows that vulnerable groups have already been significantly impacted by the changes implemented in 2015, with access issues existing not only for those who will be chargeable under the new proposals but also for those who are and will remain exempt such as asylum seekers, refugees and homeless UK citizens. Brexit throws another element of uncertainty into future plans and clarity will need to be provided on how EU citizens will access health care in the UK as restrictions could risk further marginalization of vulnerable groups from these countries.

What’s needed?
Despite the evidence-base, the voice of medical and public health professionals appears to be limited. In a ‘post-fact society’17 public health bodies, health providers and medical colleges must find new ways to urge governments to put the principles and evidenced benefits of free primary care services above political desire to be seen to be tough on immigration.