We have also published guidance for healthcare professionals which aims to provide the knowledge and tools to advocate for migrant children and their families.
‘Undocumented’ migrant - a term often used to refer to people who do not have any formal immigration status/leave to remain. People without leave to remain also do not have recourse to public funds.
NHS Charging regulations refer to restrictions to healthcare access for many migrant children, their families and other undocumented patients. These rules are set out in separate devolved legislation known as The National Health Service (Charges to Overseas Visitors) Regulations in England, Scotland and Wales, and as Provision of Health Services to Persons Not Ordinarily Resident Regulations in Northern Ireland.
UASC: unaccompanied asylum seeking child - these are young people who have migrated to the UK unaccompanied by a parent or legal guardian. They are automatically under the care of their Local Authority i.e. they are Looked After Children, and have full entitlement to free NHS care and other public services. NHS charging regulations do not apply to them.
- The UK is a signatory to the UN Convention on the Rights of the Child, which states that signatories “shall strive to ensure that no child is deprived of his or her right of access to health care services”.1
- Everyone in the UK, regardless of immigration status, is entitled to register with a GP, receive primary healthcare, and access treatment within an Emergency Department at no cost.
- For secondary care, legislation in all four nations of the UK allows, and in some cases mandates, NHS trusts to charge patients – including children - deemed “not ordinarily resident” in the UK.2 3 4 5
- There are complex exemptions to charging based on immigration status, certain patient circumstances, and for treatment for exempt conditions. More details can be found in the RCPCH guidance document Rights to access healthcare for migrant and/or undocumented children
- It is estimated that around 200,000 children currently live in the UK who lack formal immigration status6 , i.e. would be deemed “undocumented” and potentially charged for NHS secondary care.
- NHS services share patient information with the Home Office, most notably if there is an unpaid bill of over £500.
- The Academy of Royal Colleges (representing doctors from across the range of specialties) has called for suspension of NHS upfront charging.7
Harm to patients
- There is growing evidence that healthcare charging causes harm,8 9 10 including specifically to children and young people in the UK.11 This includes direct harm through denial of care, and indirect harm, for example delayed presentations through fear of charging or deportation. In an RCPCH survey of paediatricians and child health workers, there were 18 reported cases of children or pregnant women being deterred from accessing necessary care, 11 cases of care being delayed or denied outright, and 12 cases of delay contributing to worse health outcomes.11
- Even in cases where children are not charged directly, NHS charges to family members can significantly impact on children: the financial burden may cause or exacerbate poverty; the health impacts of delayed or denied treatment will cause stress and may impact on work and caring responsibilities;12 and debts to the NHS prevent families from obtaining formal immigration status e.g. applying for citizenship.13
- Data sharing with the Home Office conflicts with principles of confidentiality, which undermines relationships and trust in health care professionals.
- Fear and suspicion of the NHS, can also lead to low rates of healthcare seeking in the friends and families of those more directly affected by charging. Whilst exemptions exist for some vulnerable groups - for example recognised victims of modern slavery - the ability of health professionals to identify these exemptions is severely impaired if patients fear contact with the NHS.
- Legislation that requires NHS Trusts/Health Boards to withhold or deny available medical treatments from patients conflicts with professional obligations to treat children in their best interests. It can create situations where families, fearful of charging, decide to take their child out of hospital or delay bringing them to hospital when needed, leading to safeguarding concerns around neglect of medical needs.
Exacerbation of inequalities
- Families affected by NHS charging are disproportionately affected by the wider (social) determinants of health, such as low quality and insecure housing and are likely to be affected by racial health disparities, language barriers and societal racism.11
- Research on charging shows there is evidence of racial profiling by NHS staff in which patients of black and ethnic minority backgrounds are more likely to be targeted for status checks, have their eligibility for NHS care questioned, or be inappropriately charged,14 as has been highlighted by the Windrush scandal.15
- Many families affected by NHS charging are also impacted by other immigration legislation which impacts on their ability to work, obtain housing, and access benefits as part of the “hostile environment” policies enforced by the Home Office. This creates a cycle of destitution which leads to negative impacts on health outcomes throughout a child’s life course.16
Barriers to access
- Migrant and undocumented families face significant barriers with GP registration, and at Emergency Department reception desks.17 This means that there are significant disparities in access even to that healthcare which is legislated as free to all.
- There is widespread misunderstanding of the NHS charging regulations, including among NHS healthcare and administrative staff. This means that many patients are incorrectly billed, despite being fully eligible for NHS care.8
Impact on healthcare professionals
- RCPCH research suggests that the legislation may have a detrimental effect on NHS staff, who feel stressed by the moral dilemmas in which NHS charging places them.8 In addition, many NHS staff have family who are themselves directly impacted by the charging legislation.
Key messages for child health professionals
- Immigration checks within healthcare are carried out by Overseas Visitors Managers, or other administrators, and are not a clinician’s direct responsibility. However such checks can jeopardise patient relationships regardless of who completes them.
- Healthcare professionals can often play a role in advocating for individual patients to receive the healthcare they need.
- Healthcare professionals are often particularly well placed to identify young people and carers who are survivors of trafficking or modern slavery. This resource18 provides useful information in addition to resources and support provided by NSPCC.
- For further details about a clinician’s role in relation to NHS charging - including the responsibility in England and Wales to determine if secondary care is “urgent or immediately necessary” - please see the RCPCH’s guidance document Rights to access healthcare for migrant and/or undocumented children
What is RCPCH doing about this?
We need the same access to healthcare for all
- We provide guidance for child health professionals on supporting patients and families who are facing NHS charging.
- We host a reporting tool, to facilitate ongoing data collection on the impacts of NHS charging, and wider immigration policy, on child health.
- We recognise the ethical dilemma which charging legislation places members in, and commit to supporting members in advocating both for individual patients and for wider healthcare access.
- We are committed to working with relevant authorities and agencies across the UK to progress the recommendations listed in this position statement.
- We will consider the specific needs of migrants (including our patients and our members) within RCPCH policies, including Equality, Diversity and Inclusion strategy.
RCPCH calls on the UK government to:
- Abolish the legislation that provides for NHS charging in all four nations of the UK
- Ensure that patient data remains confidential within the NHS, is not shared with the Home Office, and cannot be used for immigration enforcement purposes
- Stop any expansion of NHS charging and protect universal access to primary care and public health services.
Guidance: rights to access healthcare
In November 2020, we published guidance which gives healthcare professionals the knowledge and tools to advocate for migrant children and their families. This guidance, which should be used in conjunction with local Trust policy and is applicable UK-wide, helps clinicians recognise those families who are most vulnerable and advises on how to provide support.
- 1UN General Assembly. Convention on the Rights of the Child. (1989).
- 2Acute Care & Workforce/Provider Efficiency &Productivity/Cost Recovery Programme/ 13790. Making a fair contribution: government response to the consultation on the extension of charging overseas visitors and migrants using the NHS in England. (2017).
- 3Welsh Assembly Government & NHS Wales. Implementing the Overseas Visitors Hospital Charging Regulations. (2009).
- 4The Department of Health, Social Services and Public Safety. Provision of Health Services to Persons Not Ordinarily Resident Regulations (Northern Ireland) 2015. vol. 2015 No. 27 (2015).
- 5National Health Service, Scotland. The National Health Service (Charges to Overseas Visitors) (Scotland) Regulations 1989. 1989 No. 364 (S.40) (1989).
- 6Mayor of London. London's Children And Young People Who Are Not British Citizens: A Profile. London: University of Wolverhampton: Institute for Community Research and Development. (2020) Accessed March 2021 at: www.london.gov.uk/sites/default/files/final_summary_londons_children_and_young_people_who_are_not_british_citizens.pdf
- 7Academy of Medical Royal Colleges. NHS charges to overseas visitors regulations - A statement from the Academy of Medical Royal Colleges. (2019).
- 8 a b c Nellums, D. L. B. et al. The lived experiences of access to healthcare for people seeking and refused asylum. 77 (2018)
- 9Potter, J.L., Burman, M., Tweed, C.D. et al. The NHS visitor and migrant cost recovery programme – a threat to health?. BMC Public Health 20, 407 (2020).
- 10Nellums DLB, et al. Access to healthcare for people seeking and refused asylum in Great Britain. 121. Research Report: Equality and Human Rights Commission (2018).
- 11 a b c Murphy, L. et al. Healthcare access for children and families on the move and migrants. BMJ Paediatrics. Open 4, e000588 (2020) Available at https://bmjpaedsopen.bmj.com/content/4/1/e000588
- 12Maternity Action. What price safe motherhood? (2018). Accessed March 2021 at: maternityaction.org.uk/2018/09/what-price-safe-motherhood/
- 13Department of Health and Social Care. Overseas Chargeable Patients NHS debt and immigration rules. (2019) Accessed Apr 2021 at: assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/793132/overseas-chargeable-patients-nhs-debt-and-immigration-rules.pdf
- 14Institute for Public Policy Research. Access denied: The human impact of the hostile environment. Accessed March 2021 at www.ippr.org/research/publications/access-denied. (2020)
- 15William W. Windrush Lessons Learned Review. Independent review ordered by the House of Commons (2020). Accessed March 2021 at www.gov.uk/government/publications/windrush-lessons-learned-review.
- 16Dexter, Z., Capron, L. & Gregg, L. Making Life Impossible - How the needs of destitute migrant children are going unmet. The Children’s Society (2016)
- 17Patel, A. & Corbett, J. Registration refused: a study on access to GP registration in England, Update 2017, Doctors of the World (2017).
- 18Wood LCN. Child modern slavery, trafficking and health: a practical review of factors contributing to children’s vulnerability and the potential impacts of severe exploitation on health, BMJ Paediatrics Open 2020;4:e000327. doi: 10.1136/bmjpo-2018-000327