Category Archives: Migration

Evidence and policy priorities

There are stark ethnic inequalities in health: Black Caribbean, Pakistani, and Bangladeshi people have between six and nine fewer years of disability-free life expectancy than do White British people

Ethnic Minority health

How do we understand this diversity?

Making sense of ethnic inequalities in health – The epidemiological method

‘Epidemiology is the study of the distribution and determinants of disease. The main method of study, particularly for investigating the causes of disease, is to compare populations with different risks of disease. Ethnicity is a variable that is used increasingly to define populations for epidemiological studies.’

Senior and Bhopal (1994)

  • But this encourages an unreflexive and uncritical use of the concept of ethnicity. Ethnic groups are treated as pre-constituted entities with pre-specified properties, with an emphasis on the different/exotic.
  • Explanations are then ‘read’ from the ethnic and disease categories available in data. The presumed properties of ethnic groups, be they cultural or genetic, become the source of explanation for the disease outcome.
  • Rather, we need an approach that pays attention to the processes that lead to the construction and racialisation of ethnic identities, and how these processes shape life chances – what might be called fundamental causes.

Ethnicity, social relationships and social structure

Racial and ethnic groups … are discursive formations, calling into being a language through which differences are accorded social significance, and by which they may be named and explained. What is of importance for social researchers studying race and ethnicity is that such ideas also carry with them material consequences for those who are embraced by them and those who are excluded from them.

Solomos (1998)

The ways in which identities are perceived, valued, mobilised and interacted with are shaped by economic, cultural, legal, political and symbolic resources. Important here is how emotions are attached to symbolic resources, emotions around risk, danger, fear and disgust, which then shape the practices of individuals and institutions. ‘Racial life [is] suffused with shared passions, imageries and fantasies’.

Emirbayer and Desmond 2015

Racism as the fundamental cause

  • Racism has its origins in ongoing historically determined systems of domination that serve to marginalise groups on the base of phenotypic, cultural or symbolic characteristics, thereby generating a racialised social order.
  • Explanation, then, needs to examine the role of three inter-related dimensions of racism – structural, interpersonal and institutional.
  • Structural racism is reflected in disadvantage in access to economic, physical and social resources. This does not have just material implications, but also cultural and ideological dimensions, material inequality justified through symbolic denigration.
  • Interpersonal racism (ranging from everyday slights, through discrimination, to verbal and physical aggression) is a form of violence/trauma and emphasises the devalued status of both those who are directly targeted and those who have similarly racialised identities, thereby engendering meaningful psychosocial stress.
  • Institutional racism (first coined by Carmichael and Hamilton 1967) is reflected in routine processes and procedures that translate into actions that shape the experiences of racialised groups within these institutions.
  • These disadvantages, accumulating across a life course, are the drivers of ethnic inequalities in health outcomes.
Ethnic differences in household income

Ethnic differences in equivalised household income

Low birth weight by occupational class

Low birth weight by occupational class

Standardising for socioeconomic position:

Standardising for socioeconomic position

This reflects both the particular economic location of ethnic minority groups and the multi-dimensional nature of the economic and social inequalities they face, meaning that no realistic statistical adjustment can plausibly simulate randomisation.

Racialised socioeconomic inequalities mean:

  • Lower incomes;
  • Lower status occupations;
  • Poorer employment conditions;
  • Higher rates of unemployment and longer periods of unemployment;
  • Poorer educational outcomes;
  • Concentrated in economically and environmentally depressed areas (but positive effects of ethnic density);
  • Housing tenure;
  • Poorer quality and more overcrowded accommodation.
  • And inequalities that accumulate across the life course and across generations.
Persisting ethnic inequalities in unemployment

Persisting ethnic inequalities in unemployment 1991-2001-2011

Experiences of racism and discrimination:

  • One in eight ethnic minority people experience racial harassment in a year.
  • Repeated racial harassment is a common experience.
  • 25% of ethnic minority people say they are fearful of racial harassment.
  • 20% of ethnic minority people report being refused a job for racial reasons, and almost three-quarters of them say it has happened more than once.
  • 20% of ethnic minority people believe that most employers would refuse somebody a job for racial reasons, only 12% thought no employers would do this.
  • White people freely report their own prejudice:
    • One in four say they are prejudiced against Asian people;
    • One in five say they are prejudiced against Caribbean people.

Research across outcomes and contexts consistently shows the adverse impact of racism on health (for example, Wallace et al. 2016

Racism, discrimination and health:

Changes in levels of racism

Changes in levels of racism 1993-2009

Persisting prevalence of racial prejudice

Persisting prevalence of racial prejudice 1983-2013

Institutional racism in health services?

Access to and outcomes of care:

  • No inequalities in access to GP services.
  • No inequalities in outcomes of care for conditions that are largely managed in primary care settings:
    • Hypertension, raised cholesterol and, probably, diabetes.
  • The effect of healthcare systems – a health service with universal access and standardised treatment protocols?
  • Marked inequalities in access to dental services.
  • And marked inequalities in the US insurance based system.
  • And institutional racism evident in some areas:
  • Some inequalities in access to hospital services.
  • Ethnic inequalities in reported levels of satisfaction with care received.
  • And, mental illness and psychiatric services …

Conclusion

  • Racisms are fundamental drivers of observed ethnic inequalities in health.
  • In investigating this, it is important to examine the ways in which structural, interpersonal and institutional racisms operate and constitute one another.
  • Structural conditions of socioeconomic disadvantage and interpersonal experiences of racism both create an increased risk of poor health for ethnic minority people.
  • They also shape encounters with institutions that have policies and practices that lead to unequal outcomes – education, employment, housing, criminal justice, politics, etc., as well as health and social care.
  • Institutional settings represent sites where we see the concentration and mediation of structural forms of disadvantage and interpersonal racism. This is produced via both the unwitting practices and overt agency of individuals operating within particular structural conditions.
  • Institutional racism will take different forms, will operate differently, across institutions with a different focus – for example, the functions of institutions dealing with cancer screening compared with those implementing coercive treatments for severe mental illness.

Reflecting on Policy

  • There has been little development of policy to specifically address ethnic inequalities in health, only occasional, limited and local intervention, with no real evaluation of the impact of specific or general policy on ethnic inequalities in health.
  • For example, a shocking neglect of ethnic inequality in the Marmot Review – assumption that socioeconomic inequalities are unimportant for ethnic inequalities in health, or that general policies to address questions of equity will also address ethnic inequalities.
  • But not a policy vacuum, there are clear policies around identity, culture, community, segregation and migration, all of which are likely to negatively impact on ethnic inequalities in health.
  • And ethnic minority people have been disproportionately impacted on by public sector retrenchment (austerity measures).
  • In fact, the evidence base strongly suggests that policy development should focus on the social and economic inequalities faced by ethnic minority people.
  • Need short term policies to address economic inequality (tax, employment, welfare, housing, etc.).
  • However, the economic inequalities faced by ethnic minority people cannot be addressed by policies targeted at on average reductions in economic inequalities, because such policies don’t address processes impacting on ethnic minority people – reflected in institutional practices.
  • Example: early years investments, which don’t address the emergence and persistence of racial disadvantage in the education system and labour market.
  • Example: failure of favoured ‘up-stream’ interventions, such as SureStart, to engage with and meet the needs of ethnic minority groups.
  • Example: public sector workers bearing the cost of the recession.
  • Example: rise in part-time work and zero hours contracts.
  • Rather need long-term policies that promote equitable life chances and that address racism and the marginalisation of ethnic minority people – a focus on institutions, including politics and Government, is crucial.

Institutional reform: an example

  • As an employer, the public sector has the opportunity to provide significant leadership.
  • For example, in 2017 the NHS directly employed 1.2 million people, indirectly many more, so employment practices within the NHS are able to impact on the labour market nationally and regionally.
  • Ethnic minority people are over-represented in the NHS (and public sector) workforce – 22 per cent of NHS staff are not White, compared with 13 per cent of all workers.
  • Discussion around public sector employment has focussed on enhancing efficiency by reducing labour costs, consequently opening up opportunities for private investment.
  • Instead could use this as an opportunity to implement positive and equitable employment practices, setting a standard: employment rights, holidays, sick leave, study leave, maternity leave, job security, job flexibility, guaranteed hours, limits to unpaid overtime, promoting autonomy and control, and, importantly, pension rights.
  • Such changes are likely to mostly benefit those in lower employment grades and more precarious employment conditions – ethnic minority workers.
  • Could also address the marked ethnic inequalities within the public sector workforce – ‘snowy white peaks’ – rethinking institutional structures and practices, and addressihng pay differentials.
  • Reforming institutional cultures – the whiteness of institutions – and addressing discrimination and racism in the workplace.

This was presented at our conference Public Health Priorities for Labour

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Impact on refugees, people seeking asylum, and other vulnerable groups

The Government recently proposed to amend a set of rules, known as the ‘NHS Charging Regulations’, which govern how people access healthcare in England, and when they have to pay for it. New regulations were laid before Parliament on 19 July 2017. This briefing explains what changes the new regulations seek to make – with a particular focus on their impact on refugees and people seeking asylum.

Which NHS services are currently free for everyone?

  • All GP services
  • Family planning services, compulsory mental health care, and treatment for a range of communicable diseases that might pose a public health risk and treatment provided in a sexually transmitted diseases clinic
  • Treatment of a physical or mental condition caused by torture, female genital mutilation, domestic violence or sexual violence when the patient has not travelled to the UK for the purpose of seeking such treatment
  • Accident and Emergency services

Health services affected by extending charging

  • Health Visiting
  • School Nursing
  • Community Midwifery
  • Community Mental Health Services
  • Termination of Pregnancy services
  • District Nursing
  • Support Groups
  • Advocacy services
  • Specialist services for homeless people and asylum seekers

Some people in the UK are not entitled to free NHS hospital care. This includes people who are here for short-term visits, undocumented migrants, and some asylum seekers whose claims have been refused. The situation is different in Scotland, Wales and Northern Ireland, where devolution agreements allow for different healthcare arrangements. There are already processes in place for hospitals to identify and bill patients for their care. The Government has now made new regulations extending NHS charges to community healthcare services, and placing a legal requirement for all hospital departments and all community health services to check every patient’s paperwork and charge up front for healthcare; refusing non-urgent care where a patient cannot pay. These two changes are looked at in more detail below:

Extending charges into community services

From August 2017, healthcare charges will be introduced for services provided by all community health organisations in England, except GP surgeries. Any organisation receiving NHS funding will be legally required to check every patient before they receive a service to see whether they should pay for their care and, in some circumstances, patients will be charged for accessing these services. See  full list of exemptions.

A wide range of health services may be affected (see above for details), including NHS organisations and, as of October, community interest companies and charities. These services are often specifically commissioned to reach marginalised communities and individuals unlikely to seek out NHS care. The introduction of charges undermines the vital role they play in protecting public health and safeguarding children and vulnerable adults. The Government has made multiple commitments to carry out an assessment of the unintended consequences of extending NHS charges on vulnerable people, pregnant women and children4, but this has not happened.
As we read the regulations, public health services commissioned through Local Authorities, which include public mental health and drug and alcohol services, will also be affected.
While the regulations do not alter the fact that GP services and Accident and Emergency5 services are currently free to all, the Department of Health have indicated this may be subject to review at a later date.

Introduction of upfront charging

From October, every hospital department in England will be legally required to check every patient’s paperwork before treating them, to see whether they are an overseas visitor or undocumented migrant and should be charged for their care. Every patient, British citizen or person under immigration control, will be asked about their residency status and will need to prove they are entitled to free NHS care. Pilots requesting all patients to provide two forms of identity prior to appointments are being carried out in 20 hospital trusts across England. The obligation to check patient paperwork applies to services exempt from charging on public health grounds, such as infectious disease departments and HIV clinics.
If a patient cannot prove that they are entitled to free care, they will receive an estimated bill for their treatment and will have to pay it in full before they receive any treatment other than that which is ‘urgent’ or ‘immediately necessary’, as defined by doctors on a case-by-case basis.
The regulations also introduce an obligation on trusts to record that a patient is not entitled to free NHS secondary care against that patient’s NHS number. Both this measure, and up-front charging, were not included in Department of Health’s 2016 consultation on NHS cost recovery and as such have not received public scrutiny.
These changes have been laid before parliament and will become law without debate unless there is an objection from either House.

What does this mean for refugees and people seeking asylum?

Refugees and people seeking asylum are exempt from paying for treatment. However, refused asylum seekers have different entitlements. Those in receipt of some form of statutory support (Home Office Section 4/ Section 95 support or Local Authority support) are entitled to free care. However, in England, refused asylum seekers who are not in receipt of support are currently chargeable for secondary (hospital) care, unless they started their course of treatment prior to being refused or qualify for a treatment based exemption (for example, they are HIV positive). The situation is different in Scotland, Wales and Northern Ireland, where the devolved governments have seen fit to ensure refused asylum seekers can still receive healthcare for free.
Under the new regulations, refused asylum seekers would become chargeable for a range of community health services in England, and would also be subject to up-front charging for non-urgent care.
Even under the current system, it is difficult for health services to accurately identify who is chargeable under the regulations and who is exempt, particularly when the immigration status of individuals regularly changes over time. Those who are most adversely affected are often the most vulnerable, who have little understanding of their rights or ability to advocate for themselves and navigate the NHS, particularly without a translator.

The result has been that all too often, even those who are exempt from charging – such as refugees and asylum seekers – are wrongly denied or charged for treatment, or deterred from accessing treatment altogether for fear of being charged. We are concerned that new plans to extend the charging mechanisms within the NHS will further deter people seeking refugee protection from accessing the healthcare they need.
Our key concerns about regulations to extend charging into community care settings, and introduce up-front charging are:

  • Up-front charging and the need to present paperwork proving eligibility for free care will increase barriers to healthcare for refugees, asylum-seekers and other vulnerable groups: There is a risk that healthcare, including lifesaving care, may be withheld from refugees and asylum seekers who are entitled to free care because they do not have easy access to paperwork and passports to prove entitlement. Other vulnerable groups, such as victims of trafficking, homeless people, elderly people, and those living with mental health conditions are also likely to be affected.
  • Preventing hard-to-reach communities from accessing essential services will lead to increased health inequalities: Any NHS funded organisation – including charities – that provides community based services such as termination of pregnancy services and community mental health services, will be legally required to check the eligibility of patients and, in some circumstances, charge patients. These services are often specifically commissioned to reach marginalised communities and individuals unlikely to seek out NHS care. The introduction of charges undermines the vital role they play in safeguarding children and vulnerable adults, and will result in increased health inequalities.
  • The extension of charging will have dire consequences for refused asylum seekers: Denying healthcare doesn’t make health problems go away. Due to their experiences in their country of origin, their journey to the UK, and sometimes their experience in the UK asylum system, people seeking asylum often have particular physical and mental health needs. Additionally, the poverty, homelessness and social isolation faced by many refused asylum seekers can exacerbate existing health conditions. With no permission to work in the UK, they are unlikely to have any means of paying for health services, and will be deterred from accessing even those services that are free for public health reasons due to fear of being charged at a later date, or being identified by the Home Office. Both the Welsh and Scottish governments, and Northern Irish Assembly have seen fit to exempt this group from charging.
  • These measures will further undermine public health: Taken together, the extension of charging into community care services, coupled with the likelihood that public health services commissioned through Local Authorities – such as drug and alcohol services – will also be affected by the regulations, mean that access to immunisation programmes, early diagnosis of communicable diseases, and other preventative care programmes which protect us all will be undermined.
  • All this will cost the NHS more money: The Government has not carried out a full and robust assessment of the impact and cost of the new charging regime. The anticipated financial saving for the NHS is small (£200,000 a year), based on little evidence and likely to be overestimated. For example, it is estimated community services face a cost of up to £13.64 per provider per year to cover the retraining of staff and associated administrative costs of implementing the cost recovery programmes, but this fails to properly to take into consideration additional administrative time to check paperwork. In addition, the confusion around eligibility will result in late diagnosis and treatment amongst groups most at risk, with significant long-term costs to the NHS, particularly when considering emergency interventions undertaken after an individual’s health has deteriorated and they require urgent or immediately necessary treatment. A case study from Northern Ireland during the period when migrants were charged for primary and secondary healthcare illustrates this point: An asylum seeker could not get access to an inhaler for her asthma after her asylum application was rejected. She consequently became so ill that she was admitted to the Intensive Care unit at Belfast hospital in November 2012 and had to stay in hospital for five days before being discharged. In her case, the cost of a prescription would have been £12.87, while the cost of a visit to A&E by ambulance and five days in hospital was £1,508.
  • New systems to check patient eligibility will have unintended consequences: As ID checks are carried out on all patients in advance of appointments, and medical professionals are tasked with judging whether treatment is urgent or immediately necessary, patient waiting times are likely to increase, putting the NHS under even greater strain. There is also the risk of racial profiling being used as a means to identify chargeable patients, leading to an increase in health inequalities (a breach of the Secretary of State for Health’s duty to reduce health inequalities under the Health and Social Care Act 2012). The only way to check eligibility for free NHS services which does not contravene equality law is to check everyone. Reviewing every patients’ immigration status will be time consuming, costly to administer and frustrating for both patients and NHS staff. It is difficult to see how repeat eligibility checks can be avoided as service providers will have to ensure that a patient’s residency status in the UK has not changed over time. In Northern Ireland, reviews were carried out every six months, but this was later judged to be unworkable and consequently carried out every 24 months. One of the problems encountered was that the Home Office often failed to confirm people’s immigration status. Furthermore, these checks will place an additional administrative burden on the Home Office, to the detriment of their ability to manage the wider asylum system.

Recommendations

The regulations should be withdrawn. The government should carry out and make public the results of:

  • an assessment of the impact of extending charges into community services on vulnerable groups, pregnant women and children;
  • an assessment of the impact of upfront charging and checking patient paperwork on access to services, health outcomes and patient waiting times, including an evaluation of the ongoing pilots taking place in hospital trusts;
  • an impact assessment evidencing the proposed regulations do not breach the Secretary of State for Health’s duty to reduce health inequalities under the Health and Social Care Act 2012;
  • a human rights impact assessment on upfront charging;
  • a public consultation on the parts of the regulations not included in the 2016 consultation on NHS cost recovery: upfront charging and recording information against NHS number (consistent identifier);
  • a more robust and thorough assessment of the true costs of introducing these measures.

On the completion of the above, any regulations to extend charging into new areas of care and / or introduce upfront charges should:

  • exempt all services that protect public health, including drug and alcohol services, community midwifery services, health visiting and school nursing;
  • exempt all services provided by charities or community interest companies;
  • exempt all community mental health services;
  • exempt all abortion providers;
  • exempt asylum seekers whose claims have been refused, as is the situation in Northern Ireland and Scotland;
  • require all decisions to withhold healthcare pending payment to be 1) subject to a second clinical opinion and (2) open to challenge by a patient
  • be accompanied by Department of Health guidance for hospitals and doctors 1) outlining how to implement the regulations in a way that is not discriminatory and does not violate human rights or increase health inequalities and 2) confirming that routine identity documents checks should not be carried out in services where NHS charges do not apply, such as infectious disease services and A&E, or in maternity services.
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Medical translation services can be crucially important in this day and age bearing in mind that translating from one language to another can be a challenging task, especially when it comes to interpreting between patient and a doctor.

People with no or less English-speaking abilities often do not receive the health care they deserve due to language barriers. Many medical organisations do not provide translation services due to which patients suffer, unfortunately. In fact, some incidences indicate that it can cost lives as well.

It can be important in this age of modern travel as well. One might need translation for immigration purposes or apply for insurance in a foreign country. Medical translation is the means through which one can personally communicate in any language eliminating uncertainty.

Bilingual is not sufficient

Medical translation is not an easy task as mentioned above earlier. Medical terminology can make it sophisticated. Complete or partially incorrect interpretation can result in a faulty diagnosis and inappropriate treatment. Many patients rely on family members for interpretation but this is not sufficient in many cases. Using a professional service is of paramount importance in such critical situation when someone’s life is at stake.

Help for healthcare workers

Not only patients are reliant on translation services but professionals working in the healthcare field can receive immense benefits from competent translation services. From nurses to doctors to medical researchers, all can draw advantages from it. Specialists can help them comprehend test results more accurately and make sure that each and every word is properly interpreted. Translation of reports is immensely important in the medical field.

Technology

Personal communication between doctors and patients is critical but it is not facing to face anymore. Technology is progressing at a swift rate and these services can now be provided through web conferencing and video calls.

This approach provides further benefits as well. Conversations can be recorded and interactions can be reviewed all over again when in need. Items can be uploaded on the system where medical translator can access them and work on it. This even enables hospitals to cut off operation costs in multilingual areas.

Challenges

Medical translation field is high in demand and many translators are considering to move into it. But in order to provide competent services, the translator needs to have a considerable amount of knowledge and skills in their respective field. Knowledge of medicine, chemistry and pharmacology is the pre-requisite. In fact, knowledge in information technology is also important due to massive usage of technology in the medical field. Most importantly, medical translation is a field where there is no room for mistakes. Even the slightest error can put lives at risk.

This is why it is a promising field and one must consider several factors before pursuing a translation service. There are a number of services available, https://www.translateshark.com/ being one of them. Just make sure you get access to experts linguists worldwide in order to get the best services as it is crucially important to ensure a safe medical process.

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The government is using NHS patients’ personal information for immigration enforcement

The Home Office, the government department in charge of immigration, has permission to access NHS Digital records of a patient’s last known address, date of birth, GP’s details and the date registered with a GP. They can use this information to trace patients, which can result in patients’ homes being raided, sometimes leading to them being detained and deported.

Doctors of the World

Doctors of the World say their toolkit:

“Is a toolkit for healthcare professionals and GP practices who want to provide confidential and welcoming services for all their patients including refugees, asylum seekers and undocumented migrants. This advice complies with NHS England guidance on GP registration and NHS guidance on secondary care. Taking the suggested steps in this guide will also help GP practices demonstrate to the CQC that their service is responsive to patient’s needs.”

And they add:

“Deterring refugees, asylum seekers, victims of trafficking, and other vulnerable people from getting healthcare has serious health consequences. At Doctors of the World’s clinics, we regularly see pregnant women avoiding antenatal care, as well as cancer sufferers and parents with unwell children who are afraid to see a doctor. Ten per cent of our patients already do not access NHS services because they fear arrest. We fear this will now get worse.

“Patients who don’t have a GP are more likely to end up going straight to A&E and to leave conditions until they are more advanced and more expensive to treat.

“And, of course, when more people are treated for illnesses, society becomes healthier for everyone.

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In the past few days, the misleading term ‘Comprehensive Sickness Insurance’ (CSI) has suddenly become a hot topic among EU citizens in the UK. For many of them, as well as their British relatives and friends, this was the first time they have ever heard about CSI. The chilling discovery was that for many years now the CSI has been a requirement for all EU citizens studying in the UK or residing here as self-sufficient persons. Without it, they cannot exercise their treaty rights and acquire permanent residency, which would normally be automatically granted after spending a continuous period of five years in the UK. At the moment, without a valid CSI the years spent in the UK do not count towards PR. Ominously, the current rules – some of which were introduced as recently as February 2017 – seem to give the Home Office the power to deport EU nationals who are not exercising treaty rights.

The British media scrambled to publish curious assurances that the rules on deportation will not be acted on, and if they were, only selectively. The Independent went as far as quoting an immigration barrister saying that he does not think that “the Home Office is going to enforce this against say, the French wife of a British citizen. I think they’re using it against people they don’t like, like Polish rough sleepers.”  While these speculative news reports were not particularly reassuring, they highlighted a passive acceptance of the arbitrary and demeaning use of regulations.

The Comprehensive Sickness Insurance is a concern for thousands of EU nationals who, during their period of residence in the UK that would otherwise count towards PR, were at any time either a student, or a self-sufficient person (e.g. carers, stay-at-home spouses, or part-time workers not earning enough to cross a threshold set by the government). This would include cases in which an EU national worked full-time for 4 years and then enrolled at a UK university without having a CSI, thus unwittingly interrupting the 5-year residency rule.

Permanent Residency card

Permanent Residency card issued by the Home Office, image by @RochDWlicensed under Public Domain Mark 1.0

A failure of communication

It is hard to understand why the fact that the Comprehensive Sickness Insurance is a central requirement for many EU citizens in the UK has surfaced only now. It is indicative of a systematic failure of public communication that so many have learned about it only through confusing posts on social media. Many of the posts spoke of fears of deportation, of not being let back into the UK after holidays abroad, or being separated from British children or spouses at the border once Article 50 is triggered.

The official governmental channels of communication have done their best to be opaque on the topic of CSI. Also, while the House of Lords and many institutions and individuals, including British citizens living in the EU, have been calling for EU citizens’ rights to reside in the UK to be secured, it is not clear if this would involve any amendments to the CSI requirement. At least up until the time of writing (13 March 2017), the UK government website used the following description for a ‘qualified person’ who could apply for a registration certificate, and ultimately also for PR:

Fig 1: Information on Permanent Residency on the gov.uk website (13/03/2017).

Unfortunately, this information is rather incomplete, and EU nationals acting on it could unknowingly lose their right to acquire PR, and face uncertainty over their legal status.This might have been avoided if only the UK Government website was upfront about who might classify as a ‘qualified person’ (Fig 2):

Figure 2: Suggested amendments for improving  the gov.uk website on residency in the UK for EU/EEA nationals

Information on Comprehensive Sickness Insurance is curiously sparse on the gov.uk website. CSI is mentioned briefly in the guidance notes and the PR application, documents that very few would have checked before actually beginning their application process. This is particularly unlikely as the gov.uk website seems to discourage EU nationals from applying for residency certificates:

Fig. 3: Information on the gov.uk website suggesting EU nationals do not need to apply for residency certificates

More broadly, the UK government has been passing laws on CSI without communicating them widely, not even through the organisations directly in contact with EU citizens, such as universities. EU nationals arriving to the UK have not been provided with clear information on the requirement to obtain health insurance in order to secure their rights.

Not so ‘comprehensive’ after all

Once an EU citizen somehow finds out about Comprehensive Sickness Insurance, they face another challenge – there does not seem to be a reliable source of information on what private insurance coverage would qualify as CSI in the eyes of the Home Office. Some private insurers advertise CSIs, but state they are not liable if their insurance ends up not meeting requirements. An insurance broker contacted by the author claimed that the Home Office has not issued guidelines on CSI and that they go by what is reported in the media and by their own experience with PR applications.

The mere fact of having health insurance from another EU country does not necessarily mean an EU citizen has CSI. They should have had a European Health Insurance Card (EHIC) issued by another EU member state for every period in which they were a student or self-sufficient person in the UK. However, by being a resident in the UK, some EU citizens may have lost access to healthcare in their country of origin. In a further administrative paradox, relying on an EHIC issued by another EU country for the PR application will only be accepted if one confirms their intent not to live in the UK permanently (see Fig 3).

Comprehensive Sickness Insurance

Fig 4: Screenshot from the PR application and a note on CSI requirement.

It is unclear as to how the Comprehensive Sickness Insurance would relieve the potential burden an EU citizen might pose to the NHS. The PR application only requires one to have a CSI, not to have made use of it. Indeed, people with CSIs can still access GPs and all treatments on the NHS. EU citizens are in many circumstances required or strongly encouraged to register with a GP (including when enrolling at a university). Moreover, private insurers do not cover all treatments (even under the ‘comprehensive’ sickness insurance), often delegating the treatment of chronic conditions to NHS.

Furthermore, CSI is discriminatory. Contrary to the Immigration Health Surcharge paid by international students in the UK, there is no standardised rate for private CSI for EU nationals. The CSI premiums depend on one’s age, sex, health, and prior conditions, among others. This disadvantages EU nationals who are women, older, have comorbidities or prior health conditions. Even the cheaper options for healthy young adults (c. 30-40£/month) could be difficult to afford.

Obtaining CSI seems to be a purely administrative, box-ticking task for the PR form, without much real-life relevance or benefit to EU citizens, or to the NHS. In its current form, the CSI confers an unnecessary financial burden and a discriminatory barrier to residency.

How about the universities?

It seems that the UK universities were not prepared to offer their EU students (some of whom are their former employees) comprehensive information about Comprehensive Sickness Insurance. In certain cases, they offered false reassurance that EU students do not require health insurance. For example, still in February 2017, the UCL website dedicated to health advice contained the following statement: “If you are an EU/EEA student, […] you may wish to consider private health insurance as well as there can be long waiting times for some NHS services. […]. However, medical insurance is not compulsory and is your decision whether you wish to purchase it or not.” A few days before the publication of this article, a rather unhelpful statement was added: “For EU/EEA students, the information provided above concerning medical insurance is relevant for accessing healthcare during your time as an enrolled student at UCL. More information about comprehensive sickness insurance can be found on the UK Council for International Student Affairs (UKCISA) website.”

This further testifies to the lack of clear guidelines and bureaucratic chaos surrounding CSI, with few institutions equipped to offer specific guidance even today.

The author of this article has yet to meet an EU student who knew about the CSI before the issue surfaced in the media in the last weeks. Many still do not know about it. Some websites suggest that some university application forms for EU/EEA nationals ask whether the student holds CSI. However, given the legal implications of not having CSI, it does not seem sufficient to be informing students about it via a box-ticking exercise or a brief mention on application forms. Crucially, the information about CSI should always be contextualised and accompanied by information clarifying that (i) access to the NHS does not count, and (ii) that CSI is required to exercise treaty rights and accumulate residency rights.

What should have been done about CSI

The Comprehensive Sickness Insurance regulations have not been implemented effectively, but this could have been avoided. The legality, practicality, and logistics of CSI should have been scrutinised before implementing the rules, and if they were still deemed to be appropriate, then:

  1. The UK government should have been more transparent and vocal about the rules for EU citizens, and particularly CSI.
  2. There should have been procedures in place to ensure that EU citizens planning to come to the UK, and those already residing here, but also British citizens (who might be partners, in-laws, employers, tutors to EU nationals), are appropriately informed.
  3. Information about the CSI requirement should have been disseminated in a useful and non-threatening manner through many channels: at passport controls, via GPs, schools, religious associations, banks, TV and radio stations, unions, as well as universities (emails to EU students and their supervisors/tutors, at orientation days, freshers’ weeks, special inductions). Such an information campaign should have been initiated ahead of the proposed changes to legislation and should have continued ever since.
  4. A simple government website should have been set up with comprehensive information on CSI, listing (a) clear rules as to what cover would qualify for a private CSI, and (b) a list of approved providers. This could also ensure that EU nationals do not fall victim to ‘sham’ offers, or purchase wrong policies.
  5. Universities should have been provided with guidelines on CSI, and so that they could inform EU applicants about the rules, and the implications, e.g. that they may be losing their residency rights if they start degrees without being covered by CSI.
  6. The EU citizens should be provided with means to acquire CSI in time, including ‘buffer periods’ to accommodate a change in circumstances.
  7. EU citizens should be able to make direct contributions to the NHS fund, if they wish to, rather than private insurers, with the rates standardised.

Challenging the CSI requirement

The current regulations and procedures surrounding the Comprehensive Sickness Insurance requirement put EU citizens in the UK at a disadvantage when they apply for residency. Not surprisingly, CSI has been considered unlawful by some lawyers, and has been challenged in UK courts already, but with no success. Several petitions and MPs have also called for abolishing the rule. EU Rights Clinic tries to put a new case together and calls for stories on PR being denied due to lack of CSI. The time is also high for UK universities to join their plea to protect the rights of their current and former students.

Abolishing the CSI requirements altogether, and especially for PR applications, seems the only reasonable course of action. However, abolishing the CSI itself will not be meaningful without further securing EU nationals’ rights in the UK post-Brexit.

This article first appeared on the LSE Brexit blog

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The National AIDS Trust (NAT) is the UK’s leading charity dedicated to transforming society’s response to HIV. NAT provide fresh thinking, expertise and practical resources. They champion the rights of people living with HIV and campaign for change.

On Wednesday, January 25, 2017 NAT issued the following Press Release:

Yusef Azad, Director of Strategy, said: “We strongly disagree with the decision by the NHS to hand over patient information to the Home Office immigration authorities. Patient confidentiality is one of the cornerstones of an ethical and effective healthcare system.

“We are especially worried at the impact on trust in the NHS among migrants. They include people who have been tortured, or trafficked, people who have serious communicable diseases, people who have vulnerable dependents including children. The migrants affected by these measures retain the right to access a wide range of NHS services perfectly lawfully. They should have assurance of the same confidentiality rights as anyone else.

“A significant proportion of people with HIV in England are migrants. This sharing of information with the Home Office could well undermine HIV testing and care, and poses a risk both to individuals and to public health. We call on NHS Digital to suspend this service to the Home Office and consult properly on these proposals.”

On Feb. 10, 2017 BuzzFeedNews carried a story entitled: Ministers accused of “Out-Trumping” Trump:

“The NHS is now required to hand the Home Office the addresses of people it suspects of being in the country illegally under a new policy that has led to the government being accused of “out-Trumping Donald Trump”.

You can read the whole story here: https://www.buzzfeed.com/jamesball/trumping-donald-trump?utm_term=.twAMgd8m7#.rexrNRMkn

 

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The Tories must not use Brexit to harm the NHS

Our national health service relies on the skills and dedication of workers from all over the world. If you have ever been treated for an injury, have had your life saved or given birth on the NHS, it is likely that an overseas worker will have helped. It is the United Nations of healthcare.

That is why so many across the country are concerned about the impact of this Government’s approach to immigration. We know that Theresa May has chosen to prioritise immigration over trade in Brexit negotiations, no matter the impact on the economy, British business, public finances or working people’s living standards. What is less clear is the impact this will have on the NHS’ ability to meet patients’ needs.

The Government has repeatedly suggested that they will introduce a work permit scheme for EU nationals after we leave. They have said they want to achieve a largescale reduction in overseas workers in the NHS. And they have also doubled down on their arbitrary and extreme target to reduce net immigration to the “tens of thousands”. Achieving these ambitions will undoubtedly mean a significant reduction in the numbers of EU nationals working in the UK, and could therefore target those in the NHS, which currently stands at nearly 60,000 staff.

The contribution of EU nationals to our healthcare system is immense. There are over 10,000 doctors, over 20,000 nurses and over 1,000 midwives. We should welcome and celebrate their contribution and recognise it as part of our national fabric. Liam Fox, however, has shamefully said that EU nationals here in the UK were “cards” in forthcoming EU negotiations, but no-one should be a pawn for ministers to trade away. I therefore support calls for all EU nationals that are already here have their rights protected – including those working in the NHS.

Now, however, ministers must go further and commit to allowing the NHS to continue to be able to freely hire European workers to fill posts in the years ahead after we officially leave the EU. The NHS should not be hamstrung by any future work permits scheme. There should be no change in the NHS’ ability to hire EU nationals after Brexit.

The NHS needs the skills of EU medical staff. If current capability to embrace these skills is hindered as a consequences of a flawed future immigration policy our healthcare system will be weaker. This would be a betrayal of all who rely on the many millions who rely on the NHS, but also the Leave voters who voted to make the NHS stronger.

It is true that the Government’s mishandling of healthcare since 2010 means the need for overseas talent is greater than ever, but this campaign should not be a partisan issue. MPs and campaigners from all sides should get behind a strong NHS based on the skills we need and a Brexit settlement that protects our public services. That’s why I’m pleased to be supporting the cross-party Open Britain campaign, which is leading the charge on these vital issues. They are working with leading Royal Colleges and health experts, as well as politicians, to ensure the Government’s post-Brexit immigration crackdown does not harm the NHS.

Our response to the referendum should be fair and proportionate. We don’t want to harm the economy or give succour to immigration scare stories that are without foundation. Indeed, I start from a position where I believe immigration is essential for our economy and makes our society more vibrant and innovative. Any reforms need to ensure people’s concerns are met but also that the benefits of migration are not lost. One of those is a strong NHS.

This was first published on Labour List

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Migrants’ free access to the NHS and the perceived health care costs associated with it have generated much debate in the UK and even resulted in the introduction of a fee for certain non-EU citizens. Some politicians have blamed migration for the increase in waiting times, particularly in A&E.

In order to inform this heated debate we have started a new project at the University of Oxford, investigating the relationship between immigration and the NHS. Our first paper investigates the link between immigration into an area and waiting times for A&E, outpatients (referrals) and elective care (pre-arranged, non-emergency care, including scheduled operations).

Using data from 141 local authorities in England, merged with administrative information drawn from the Hospital Episode Statistics (2003-2012), we found no evidence that immigration increases waiting times in A&E and elective care. In fact, we found that higher immigration in an area actually reduces waiting times for outpatients there. On average, a 10 percentage point increase in the share of migrants living in a local authority would reduce waiting times by slightly more than 9 days. Using previous estimates of patients’ willingness to pay for a reduction in waiting times, we estimate that a 10 days reduction in waiting time would be equivalent to a person receiving about £38 in 2013 prices.

The “healthy migrant effect” and UK-born mobility

We look at two alternative explanations for our results. First, we confirm findings from previous research which suggest that migrants are younger and healthier than UK-born individuals, which in turn suggests a smaller impact on the demand for healthcare. Migrants in England are also 8 percentage points less likely to report a long-term health problem than their UK-born counterparts. By using data from the Understanding Society survey we also show that migrants’ likelihood of using hospital services is not statistically different from the UK-born. Moreover, recent migrants (i.e. those who came after 2000) are significantly less likely to use hospital services compared to the UK-born.

Second, we find that higher levels of immigration increase the likelihood of UK-born individuals moving from that area, a conclusion that has also been supported in previous studies. This means the effects of immigration on the demand for health care services are dispersed throughout the country via internal migration.

Evidence for the period immediately following the EU enlargement

We test the robustness of the results by including data up to 2007, to focus on the years immediately following the 2004 EU enlargement. The enlargement induced a sharp increase in the number of recent migrants and it could have affected waiting times, at least temporarily. Our overall results are not affected by this change. Immigration has a statistically significant negative effect on waiting times for the period 2003-2007.

We also explored geographical differences on the impact of immigration on waiting times during this period. We explored two possibilities in this regard. First, we exclude London from the analysis. The exclusion of London results in an insignificant effect of immigration on outpatient waiting times for 2003-2007.

As a second possibility, we analyse differences in our results by level of deprivation of the area, and find that immigration increased waiting times for outpatient referrals in deprived areas outside London during this period. The effect for deprived areas is not significant for the whole 2003-2012 period, but only for the period immediately following the EU enlargement (i.e. 2003-2007).

Immigration not to be blamed in most cases, but location and time matters

The ultimate effect of immigration on NHS waiting times in a specific area depends on the characteristics of that area. For most areas, immigration has no overall impact on waiting times for A&E and elective care, and leads to a reduction in waiting times for outpatients. Yet, this is not true of every single area every single period. Policymakers should take these differences in impact across areas and time into account when creating policies to reduce NHS waiting times and/or manage the consequences of immigration.

It is worth noting that because of its demographic composition, immigration may have a greater impact on maternity services. Effects could also change in the long-run as migrants become older. In particular, as low-skilled immigrants are more likely to work riskier jobs, morbidity in this group may increase in the long-run. Our project is currently looking at these two aspects.

This article by Osea Giuntella, Catia Nicodemo and Carlos Vargas-Silva was first published on the British Politics and Policy blog

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Refugees in Calais speak of desperate conditions

As the sun sets on Calais, a new barbed wire fence glints in the evening light, casting a shadow over the growing migrant camp known as the “New Jungle”.

Through the thick undergrowth of what was once an industrial dumping ground, tents and tarpaulin structures stretch into the distance. These are the makeshift homes currently providing insufficient shelter from the elements for more than 3,000 refugees. On the other side of the fence, cars and lorries trundle towards the port of Calais – and the northern edge of the Schengen Area, where people can move freely across much of Europe.

With Operation Stack in full force, and the British prime minister, David Cameron, expressing “every sympathy with holidaymakers”, the body count at Calais quietly continues to rise. A migrant died on July 28 as he tried to reach the UK. He was the ninth person to lose his life to the Calais-Dover gauntlet between June and July.

One of hundreds of informal structures built in the New Jungle in Calais. 

Cameron has pledged that the UK government will do everything it can to deal with this situation, but sitting in the detritus of the Calais camp, it is clear that the real crisis is humanitarian and is being fatally overlooked.

We have made two visits to Calais, spending several days at a time interviewing the camp’s residents. Our research is revealing the desperate conditions in which they are living. It is time the UK and French governments took responsibility for a shared issue. So far, all migrants are being given is more barbed wire.

Life in Calais

“When I first got to the Jungle, I thought to myself: ‘is this really Europe?’” said Ilyas, a Sudanese migrant whose family were murdered byJanjaweed militia.

He showed us the rudimentary “kitchen” he uses to cook – a dusty tent propped up with branches, with no place to safely store food. Like many, he had taken the hard route to Europe, through the Sahara desert – where three of his fellow passengers perished – and then the equally deadly boat journey across the Mediterranean.

Ilyas’s friend showed us a shaky video he made on his phone of his eight-day sea crossing, this time from Egypt: “We did not have any water for three days,” he explained, flicking through his phone to show happier images of friends and family in the country he was forced to leave.

Their troubles did not end when they reached European soil. Migrants we met in Calais who landed on Italian shores report being abandoned by authorities. Young and able men, in particular, are kept in camps for no longer than a few days; many end up homeless and hungry on the streets of Italy. As Italian agencies struggle to cope with the record numbers of migrants crossing the Mediterranean, some report being explicitly told to travel to northern European countries such as France, Germany and the UK. Others say they have even been shown a map.

So a small minority of the 137,000 migrants who have arrived in Europe so far this year have ended up in Calais. The New Jungle – less than one square kilometre in area – is where thousands of migrants live in appalling conditions that would not meet any humanitarian standards.

A resident of the camp cleans his hands with water from a chemical container. 

Toilet facilities are limited. There are two dozen portaloos and a few wooden toilet blocks with no handwashing facilities. Piles of rubbish attract rats and other pests. There is only access to cold water, often at some distance from the ad hoc living spaces. It is unsurprising then that many residents told us they are suffering from fevers, stomach pains and diarrhoea.

Some residents of the camp use chemical containers to transport water to their tents – and every morning, men, women and children as young as ten can be seen queuing for hours for a rare opportunity to gain access to a shower. At every turn, migrants can be seen limping and bedraggled, visibly injured by the increasing risks they are taking to enter the UK. Others say they are victims of police brutality and local thugs. Médecins du Monde is doing excellent work in the camp, but the scale of injury and illness is increasing.

A global crisis

Calais is undoubtedly a humanitarian and public health crisis. Yet it is only a microcosm of the migration crisis as a whole. In the world today, a population the size of Italy has been forced from their homes, putting global numbers of refugees at a level not seen since the end of World War II.

A resident of the camp fills his water bottle at one of the five water points recently installed in the camp. 

Developing countries – not European nations – host most of them. Turkey alone gives refuge to 1.7m refugees from Syria. The next five countries hosting the largest numbers of refugees are Pakistan, Lebanon, Iran, Ethiopia and Jordan.

On the northern edge of the New Jungle, a huge bunker looms over the people queuing for a shower. Built during World War II to protect Hitler from invasion, it reminds us that this is not the first time Calais has been on the frontline of efforts to keep out perceived existential threats.

Britain’s home secretary, Theresa May, has pledged to spend another £7m to reinforce Fortress Calais with more barbed wire – and an archipelago of migrant camps is spreading across the continent. For her, and for the British government, this is a security threat. Spending time with the residents of the Calais camp however, things look starkly different. It’s time to wake up to the humanitarian crisis unfolding in the heart of Europe.

This article is a joint effort by  and .  It first appeared on the Conversation

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Lewisham Council supports World AIDS Day on the 1st December 2015. It is an opportunity to show support for people living with HIV, remember those who have lost their lives because of HIV and learn the facts of HIV today in the UK and worldwide.

Councillors unanimously supported a motion proposed by Councillor Alan Hall supporting World AIDS Day but expressed concern at the the Government’s plans in the Immigration Bill.  He said:

“These proposals will subject the most vulnerable asylum seekers and migrants living with and affected by HIV to further destitution and will undermine their ability to manage their health. This will subsequently affect their individual health and the wider public health.

HIV treatment is available to everyone living in the UK, regardless of immigration status, but it must be adhered to exactly to be successful. In 2012, the Government removed any residency-based restrictions on access to HIV treatment in light of the immense public health benefit of universal access. Access to and adherence to HIV treatment means that a person living with HIV can maintain good health and become effectively non-infectious by suppressing their viral load, the amount of HIV present in the body. By contrast, poor adherence increases the risk of poor virological control, which is associated with illness and also HIV transmission.

The Immigration Bill rather than strengthening the integrity of the immigration system will undermine it through forcing people into destitution, homelessness and ill health.

We anticipate the removal of basic subsistence support may even encourage some Appeal Rights Exhausted asylum seekers to lose contact with the immigration system and abscond as they will have little incentive to remain in contact with the authorities once support is withdrawn. We are particularly concerned that if the latter were to happen, it would be detrimental to those living with HIV who may also avoid accessing HIV treatment and care services out of fear of being detected by the authorities

Access to good quality and stable housing is a vital element in maintaining the health and wellbeing of all people living with HIV. Privacy and stability are essential to support the necessary daily adherence to HIV medication. Poor quality housing, including damp or poorly maintained accommodation, can endanger someone with a compromised immune system. Measures to further restrict  asylum seekers access to housing as will increase homelessness and destitution in an already vulnerable population group. Evicting  asylum seekers living with HIV runs the risk of removing the stability needed to adhere to medication and remain healthy.”

The National AIDS Trust recommends that proposals to enable landlords to evict people because of their immigration status means they do not have a right to rent are not upheld in the Immigration Bill.

Lewisham Council agreed to call on the Government to remove these provisions in the Immigration Bill and for the Government to fully fund Local Authorities for their work as the ‘budget of last resort’.

Full text of Lewisham Council’s motion is here

For more information contact the National AIDS Trust: http://www.nat.org.uk/

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Over the last two years I have been part of a small team of maternity professionals contacting and visiting pregnant women who were being held in Yarl’s Wood Immigration Detention Centre in Bedford. We volunteer for a charity called Medical Justice, which aims to defend and promote the health rights, and associated legal rights, of immigration detainees in the UK. Medical Justice advocates for many vulnerable patients but, as midwives, we were assessing and providing medical reports just for pregnant women.

Being a midwife is a huge part of my identity, my purpose and passion in life. I have worked for the NHS, volunteered for midwifery and mother’s groups and worked as a midwife in Malawi for a while. The stories of the women I met in Yarl’s Wood had the most profound effect on me. To offer what expertise and support 1 could was immensely rewarding, but the circumstances in which they were put were without a doubt the most shocking thing I have seen in my career,. All the more shocking is that this is happening in the UK, here, within our own health service.

The Centre is very like a prison, with tough security, locked door after locked door, isolation rooms and control over access to food and other basics of life. Because of their histories, most of the mothers we met were very vulnerable even before their detention. Sometimes the reasons they came to the UK (fleeing gender based violence for instance) made their pregnancies more fragile and worsened their mental health. Others had pre-existing health problems and complicated obstetric histories. 1 performed a review of cases for a nine-month period in 2013/2014, which comprised of all 21 pregnant women seen by Medical Justice during that period. There is no official record of how many pregnant women are detained, so we do not know what proportion of the total number of detained pregnant women that this review contained.

I estimated that, compared to the urban multi-ethnic trust population in which I worked, the women seen by Medical Justice in immigration detention in the above review were around seven times more likely to have  ‘high risk’ pregnancies – that is pregnancies that we would typically refer for obstetric led care and multi-professional support (such as psychiatric assessment). Additionally, of course, disruption in antenatal care and being an asylum seeker in the first place would promote most of us to seek further specialist support for these women. The NICE (2010) guidelines clearly state that ‘Recent arrival in the UK’ ,’asylum seeker or refugee status’ and ‘difficulty speaking or understanding English’ are examples of ‘complex social factors’ which require more intensive support and care. Furthermore, the CMACE Report of 201 I finds that continuity of care is particularly important in asylum seeking women, due to their increased vulnerability.

In short, these women were extremely vulnerable and often unwell. They showed remarkable courage and strength in the face of extreme adversity, but there is no doubt in my mind that the health, both mental and physical, of the women I met was worsened by detention.

Immigration detention was created to be a short term ‘holding’ place for people who were to be immediately deported. In the review of cases above, I found that the mean length of detention of the pregnant women seen by Medical Justice was 50 days. The range was 10-122 days. All of the women in the review were eventually released by about 30 week; of pregnancy and none were deported until after the birth of their babies, or were not subsequently deported at all as their asylum claims were eventually accepted. Many of them were ‘not fit to fly’ which means that they did not meet the standard international aviation criteria for health and would not be allowed to board a plane during their pregnancies. Furthermore, it is not now legal for immigration personnel to use physical force to make a woman leave the Centre and board the plane, so if a woman refuses to go, there is no way of making her do so.

Yarl’s Wood has a small health care unit, staffed 24 hours by nurses (not midwives) and managers, with a GP in attendance on most working days. The unit is run by a private healthcare company, but of course all of the clinical staff are registered with the relevant professional bodies. Sometimes the pregnant women I met with would be given kind and compassionate care. However, all too often a culture of disbelief seemed to prevail which, coupled with a lack of midwifery/ obstetric specialism, led to many worrying symptoms and alarming risk factors being dismissed by the staff. For example, I saw a case in which it seemed not to be recognised that the limits of normal blood pressure are different in pregnancy than in the non-pregnant woman.

My major concern for these women was the denial of emergency assessment and treatment and delays in allowing women access to acute obstetric care. Cases that you or I would have immediately referred into hospital were left for days, sometimes weeks, with worrying symptoms ignored, or attributed to ‘attention seeking’. Once, a woman I was very concerned about, called herself an ambulance, as she was afraid for her health and for her baby, after several weeks of increasingly severe symptoms. The ambulance was cancelled by the health care staff, without her consent.

The mothers I met told me of the extreme discomfort of being in the Detention Centre whilst pregnant. Most did not find the food palatable and the restrictions on when and what they were able to eat worsened pregnancy related sickness for many of them. Several also told me how frightened they were by the guards, and by a lack of privacy in the Detention Centre leading to sometimes feeling exposed and ashamed.

As above, we do not know how many pregnant women are in Yarl’s Wood Immigration Detention Centre, though we suspect, from very rough estimates based on what women inside are able to tell us, that it is not a very large number. The pregnant women that we saw were not deported during their pregnancies due to health concerns, and were released without deportation making their detention pointless. In addition, the immense physical and mental stress of being in a detention centre had a negative impact on many of their pregnancies, not least because of the disruption to their pregnancy care and lack of access to emergency assessment and treatment. Detention is damaging for these mothers. It doesn’t really matter what you think about immigration. Perhaps you are in favour of tougher screening for asylum seekers and further limits in the number of migrants given permission to stay in the UK, or perhaps you have more lenient views. Either way you would realise that there will always be a process to follow to assess claims for asylum and immigration. Most people would be of the opinion that such a process should be fair (everyone gets treated the same), reliable (we are able to usually tell who is genuinely in need of asylum) and humane.

Most people would also add that it should be efficient – at the lowest possible cost to the taxpayer.

The detention of pregnant women is none of these things. The cost to their wellbeing is disproportionate because of their greater health needs .Their ability to cope is reduced by the normal but difficult symptoms of pregnancy and further by their higher risk of serious pregnancy complications; they are vulnerable. Furthermore, as deportation is more difficult when a woman is pregnant, because of airlines’ health related restrictions and because the immigration personnel are not allowed to use physical force on a pregnant mother, it becomes pointless. The high cost of keeping a woman in detention, potentially causing her and her baby to suffer, only to release her without deportation, is to needlessly spend money.

I am first and foremost a midwife. My commitment to the NMC Code of Conduct (2015), as the bedrock of my professional integrity, is true no matter where a woman comes from, no matter where she is living or who is master of her. Whilst these vulnerable women are in the UK, their care must be held to the same standard that we pride ourselves on in our daily practices. I have reported my concerns through our supervisory system but since the women are almost ‘outside’ of midwifery, and can’t access midwifery care by themselves, it is hard to see what can change whilst they are still detained. The NMC Code states that we must:

  • Make the care of people your first concern, treating them as individuals and respecting their dignity
  • Work with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider community
  • Provide a high standard of practice and care at all times

(NMC Code 2015)

This is demonstrably not always the case for the women we have met in Yarl’s Wood, and this has to change.

How you can help

  • Become a midwife-volunteer for Medical Justice (see below or contact me)

Donate to Medical Justice

  • Write to or email your MP with your concerns

References and Links

Centre for Maternal and Child Enquiries (CMACE) Saving Mother’s Lives: 2006-08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG, I 18 (suppl. I) 1-203.

National Institute of Clinical Excellence (2010) Pregnancy and Complex Social Factors. London, NICE Guidelines.

Nursing and Midwifery Council (2015) The Code. HMSO, London.

Public Health England (2013) Guidelines for Malaria Prevention in Travellers from the UK. PHE publications gateway number: 2013054. London, HMSO.

Medical Justice www.medicaljustice.org.The APPG 2015 report on detention and Expecting Change can also be found on their website.

Tsangarides, N.,Jane Grant, J. (2013) Expecting Change, the case for ending the detention of pregnant women. Medical Justice, London.

First published in Midwifery Matters ISSUE 145 Summer 2015

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This updated briefing:

  • comments on the decision, announced by the Department of Health in February 2015, to defer proposals to extend the overall NHS charging regime;
  • comments on the introduction of the new Immigration health charge or surcharge;
  • gives detailed consideration to the National Health Service (Charges to Overseas Visitors) Regulations 2015 due to come into force on 6th April 2015;
  • provides an overview of the charging regime for NHS hospital services currently in place and notes some key changes associated with the National Health Service (Charges to Overseas Visitors) Regulations 2015.

The Department of Health decision to extend the charging regime beyond hospitals on hold

The Department of Health announced that a decision has been taken to deprioritise extending and amending charging in primary care in order to focus on making the existing charging regime work better and introduce the new immigration health charge. However, we understand that the current Government still intends to look at extending charging beyond the current rules.  If implemented, the extended charging regime, could in due course lead to:

  • the introduction of charges for A&E care, outside EHIC collection in NHS hospital settings (supposedly without compromising rapid access to emergency care for those in immediate or urgent need); and
  • the extension of charges, in NHS services outside NHS hospitals, to the majority of NHS services including community services, dentistry, optics and pharmacy and extending current charges to treatment provided by all commissioned providers of NHS services.

Subject to the outcome of the general election in May 2015, consultations with various stakeholders and interested parties will take place before a final decision is taken as to whether to extend charging into primary care and A&E; these consultations will not take place before the autumn of 2015. However we should not be complacent and the recent assessment by the Migrants Rights Network strikes an important cautionary note.

The new Immigration health charge or surcharge

The Immigration Act 2014 gives the Secretary of State the power to issue an order to require certain migrants (those seeking leave to enter, remain or entry clearance) to pay an immigration health charge. (Regulation 10, The National Health Service (Charges to Overseas Visitors) Regulations 2015)  Whilst previously it had been thought that the rate might be £150 for international students and £200 for other categories, it would now appear that the charge may be considerably higher, possibly £600 per person. However, the actual rate will need to be confirmed in statutory regulations. The statutory regulations containing this order are due to be laid before Parliament and are meant to come into force in April 2015.

The National Health Service (Charges to Overseas Visitors) Regulations 2015

According to guidance on the DH’s website on the changes:

  • Overseas visitors who need healthcare while in England will soon be charged differently for using the NHS as part of efforts to recoup £500 million a year by 2017 to 2018.
  • From April [2015], the way the NHS charges these visitors is being changed so that it does not lose out on income from migrants, visitors and former residents of the UK who have left, who should all pay for their care while in the country.
  • Within the UK, free NHS treatment is provided on the basis of someone being ‘ordinarily resident’. It important to note that changes in the Immigration Act 2014 redefine and provide a more restrictive definition of ‘Ordinary residence’. It is not dependent upon nationality, payment of UK taxes, national insurance contributions, being registered with a GP, having an NHS number or owning property in the UK.
  • The changes which come into effect from April 2015 will affect visitors and former UK residents differently, depending on where they now live.
  • Treatment in A&E departments and at GP surgeries will remain free for all.

The regulations are divided into 5 parts and 4 schedules. 5 of the regulations (3-7) focus on making and recovering charges. NHS bodies are required to recover charges from individuals unless the NHS body has determined that the individual is exempt (regulation 5). The rate of charge will depend on whether the individual comes from a country that is a member of the European Economic Area (EEA). For those who come from outside the EEA the charge will be set at 150% of the NHS national tariff for any care they receive.  ‘People who live outside the EEA, including former UK residents, should now make sure they are covered by personal health insurance, unless an exemption applies to them. Anyone who does not have insurance will be charged at 150% of the NHS national tariff for any care they receive.’

The National Health Service (Charges to Overseas Visitors) Regulations 2015

The DH’s Implementation Plan, published in July 2014, stated that where vulnerable groups are not currently exempt, the DH  would consider ‘strengthening exemptions, or other ways of ensuring necessary treatment is provided, for victims of domestic violence, human trafficking and vulnerable children.’ The plan also stated that ‘the Government committed to ensuring that any new system takes into account international law and our humanitarian obligations… vulnerable groups such as asylum seekers, refugees, humanitarian protection cases, victims of human trafficking and children in Local Authority care will continue to have free access to the NHS and will not be subject to the surcharge.’ The exemptions are overviewed in appendix 1 (5). Broadly speaking the scope and range of these exemptions are very welcome. However, it is unclear:

  1. how all those who are exempt will be identified;
  2. how practical or realistic it will be to recover the £500 million a year by 2017 to 2018 planned by the DH;
  3. how any financial shortfalls will affect hospitals and their budgets;
  4. what actions will be taken to ensure that racial profiling will not determine who will be asked for their papers/ documentation to prove their immigration status;
  5. how the complex range of exemptions will be operationalized by NHS staff and made clear to would be service-users.

This note was first published, with more detail, by the Race Equality Foundation.  If you would like to receive further updates from Leander Neckles, please sign up to the Race Equality Foundation’s monthly e-bulletin.

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