Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG geförderten) Allianz- bzw. Nationallizenz frei zugänglich.This publication is with permission of the rights owner freely accessible due to an Alliance licence and a national licence (funded by the DFG, German Research Foundation) respectively.Charging migrants for access to health services will not reduce strain on the NHS, say Lilana Keith and Ewout van Ginneke

Ginneken, Ewout van

Keith, Lilana

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MIGRANT HEALTHRestricting access to the NHS for undocumentedmigrants is bad policy at high costCharging migrants for access to health services will not reduce strain on the NHS, say Lilana Keithand Ewout van GinnekenLilana Keith interim programmes director, Platform for International Cooperation on UndocumentedMigrants, Brussels, Belgium, Ewout VanGinneken senior researcher, Berlin University of Technology,Berlin, GermanyThe shocking loss of life among migrants crossing theMediterranean and the UK government’s refusal to contributeto European search and rescue efforts despite public outcry havethrown into sharp focus the dehumanisation of migrants throughnegative political rhetoric and policies. Migrants’ right to lifeis also challenged by limited access to healthcare, particularlyin the United Kingdom, where the first of several measuresrestricting access to NHS services for migrants, in a supposed“crackdown on health tourism,” came into force on 6 April2015.1 But what are the real effects of such measures?Immigration health chargeThe new policy imposes an up-front surcharge to guaranteeaccess to NHS hospital care for people from outside theEuropean Economic Area when they submit an application towork, study, or visit their families in the UK for a period oflonger than six months or when they are already in the UKapplying to extend their visas.2 The surcharge is £200 (€275;$310) a year (£150 for students) for the maximum period oftime that could be granted—for example, £400 for a two yearvisa (in addition to the application fee). Those who cannot paywill automatically have their application rejected.Some applicants do not need to pay the surcharge, such asasylum seekers and victims of human trafficking. However, notall vulnerable groups of migrants are protected from thesecharges. There are two groups of concern. The first is peopleresiding regularly in the UK but in poverty; they may becomeirregular migrants simply because they cannot afford to paythese charges when they apply to extend their leave. The secondare undocumented migrants and their families who are tryingto regularise their residence. The majority of the estimated 618000 undocumented migrants in the UK did not enter Europeirregularly. Instead they are people who entered the country ona work or spousal visa that was linked to one particular job orpersonal relationship and was rendered automatically invalidor impossible to extend when that relationship broke down. Thisis often due to exploitation at work or domestic violence.Administrative delays, fees, and requirements are other commonreasons for people not being able to extend their leave andbecoming “undocumented.”The NHS has already been implicated; any immigrationapplication from a person who has more than £1000 of debt forNHS services is automatically rejected. The surcharge addsanother barrier that will push people into irregularity and preventsome undocumented migrants with a right to reside in the UKfrom being able to regularise their residence.This policy alone makes the UK an outlier in Europe. No otherEU country has such a structural link between immigrationapplications and access to health services. Another measure thathas been suggested, but postponed subject to further publicconsultation, is to charge undocumentedmigrants for emergencyand primary services. These services are currently provided freeof charge to all people regardless of residence status, while otherhospital care must be paid for.3 4 This is already a narrowerrange of services than provided by some other EU countrieswith significant migrant populations, such as France⇓. If theadditional measures are approved the UK’s health services willbe among the least accessible in Europe.Shortsighted and misleadingTheUK government wants the public to believe that the changesbeing proposed will make the country less appealing toundocumented migrants and will save taxpayers’ money. Thisview is shortsighted and misleading.Are undocumented migrants “health tourists”? In a survey ofmigrants visiting Doctors of the World UK’s clinic in BethnalGreen, London, only 2.6% of respondents cited health problemsas a reason for migration, far behind economic survival (39.6%)and political, religious, ethnic, or sexual orientation (23.4%).5This is in line with findings from other European countries. Thesurvey also found that 82.7% of respondents did not have accesslilana.keith@picum.orgFor personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2015;350:h3056 doi: 10.1136/bmj.h3056 (Published 16 June 2015) Page 1 of 3FeatureFEATUREto the NHS due to legal, administrative, or language barriersand fear of deportation. On average respondents had been livingin the UK for 6.5 years.The estimated 618 000 undocumented migrants living in theUK contribute to the economy through their employment,purchase goods and services (including VAT), and may evenpay or have paid income tax. They are not free riders in the NHSbut contributors. Not providing them with coverage is unfair aswell as contrary to their rights as human beings.Would it save public funds? Little is known about the cost ofgiving migrants full access to the health system compared withpartial or no access. But a few considerations are relevant.Firstly, denying access to undocumented migrants may end upcosting the NHS more in the long run. Emergency services,which must be provided at the point of need, are exponentiallymore expensive than preventive or planned care. Furthermore,the NHS can rarely recoup these costs from patients who lackthe means to pay. Secondly, not having access to preventiveservices may lead to outbreaks, with subsequent costs to thehealth system and wider society. Thirdly, evidence shows thatundocumented migrants are healthier, cost less to cover, anduse services they are entitled to less than nationals.6 7 Lastly,restricting access to services based on residence status requirescomplex administration, itself a major burden on the NHS.Health professionals have also expressed concern over beingexpected to act against their professional ethics and act as borderguards.8Some countries and regions across Europe have chosen toprovide preventive and curative care to all their residents.Sweden has found that providing a range of health services forundocumented migrants is costing much less than they hadpredicted.9 At the same time, Spain, which recently restrictedaccess to care for undocumented migrants, is now making aU-turn. Until September 2012 undocumented migrants in Spainhad almost the same access to health services as other residents.The policy change allowed them access only to emergencyservices and care for pregnant women and children. However,only one regional government fully implemented the nationalpolicy, and the minister of health recently announced thatundocumented migrants would now be entitled to primary careagain, citing pressure on emergency services.10Negative knock-on effectsThe UK government is wrong to assume that charging migrantsfor access to health services will strongly reduce the strain onNHS resources. The restrictions already imposed aredisproportionate to their stated goals, as they have severalnegative knock-on effects on public health, healthcareprofessionals, medical ethics and human rights, and theadministration and finances of the healthcare system, as wellas causing direct harm to the health and wellbeing of vulnerablepeople. Rather than holding a public consultation on extendingthese charges to emergency and primary care, as the freshlyelected Conservative government plans to do, the evidenceindicates that the opposite approach would serve the UK andits NHS better. They should explore ways to providenon-discriminatory access to the NHS for all.1 Department of Health. Visitor and migrant NHS cost recovery programme. Implementationplan 2014-16. Jul 14. www.gov.uk/government/uploads/system/uploads/attachment_data/file/329789/NHS_Implentatation_Plan_Phase_3.PDF.2 UK Draft Statutory Instruments. The immigration (health charge) order 2015. www.legislation.gov.uk/ukdsi/2015/9780111128473.3 Coram Children’s Legal Centre. Access to primary healthcare for migrant children, youngpeople and families. www.childrenslegalcentre.com/userfiles/Access%20to%20primary%20healthcare%20for%20migrant%20children_Final.pdf.4 Coram Children’s Legal Centre. Access to secondary healthcare for migrant children,young people and families. www.childrenslegalcentre.com/userfiles/Access%20to%20secondary%20healthcare%20for%20migrant%20children_Final%282%29.pdf.5 Chauvin P, Simonnot N, Vanbiervliet F, Vicart M, Vuillermoz C. Access to healthcare forpeople facing multiple vulnerabilities in health in 26 cities across 11 countries. Report onthe social and medical data gathered in 2014 in nine European countries, Turkey andCanada. May 2015. https://mdmeuroblog.files.wordpress.com/2014/05/mdm-intl-network-full-report-11-countries-18th-may-2015.pdf.6 Fuentes FJM, Callejo MB. Immigration and the welfare state in Spain. 2011. http://www.academia.edu/401847/Immigration_and_the_Welfare_State_in_Spain.7 Stimpson JP, Wilson FA, Eschbach K. Trends in health care spending for immigrants inthe United States. Health Aff (Millwood) 2010;29:544-50.8 Abu-Hayyeh R. Immigration Act 2014 and the slow dismantling of the NHS. 2015 Apr 23.www.irr.org.uk/news/immigration-act-2014-and-the-slow-dismantling-of-the-nhs/.9 Swedish Agency for Public Management. Vård till papperslösa [Swedish]. 2015. www.statskontoret.se/globalassets/publikationer/2015/201510.pdf.10 Platform for international cooperation on undocumented migrants. European patientsforum calls for health care for all. PICUM Bulletin 2015 Apr 20. http://picum.org/en/news/bulletins/46726/#cat_25446.Cite this as: BMJ 2015;350:h3056Related linksthebmj.com• How much care is provided to migrants in differentcountries? See a related infographic online© BMJ Publishing Group Ltd 2015For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2015;350:h3056 doi: 10.1136/bmj.h3056 (Published 16 June 2015) Page 2 of 3FEATUREFigures[Image: SARAH ALCALAY / DOCTORS OF THE WORLD]View interactive map at www.bmj.com/content/350/bmj.h3056/infographicFor personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribeBMJ 2015;350:h3056 doi: 10.1136/bmj.h3056 (Published 16 June 2015) Page 3 of 3FEATURE

Restricting access to the NHS for undocumented migrants is bad policy at high cost

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Restricting access to the NHS for undocumented migrants is bad policy at high cost

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