Upfront fees ‘deterring immigrants from seeking NHS care’

Upfront charging for NHS care is deterring immigrant patients from seeking treatment, including for serious illnesses such as cancer, evidence from doctors reveals. The BMA has said that even patients with cancer are failing to get necessary treatment. The Guardian health writer Chaminda Jayanetti explores whether the ‘hostile environment’ is getting too ferocious

This is an edited version of a story that first appeared in The Guardian.

The NHS introduced upfront charging for elective care in 2017 as part of the government’s ‘hostile environment’ towards immigrants. A British Medical Association report published in April has found that pregnant women were going without antenatal and postnatal care for fear of being charged, and that patients were being informed of four-figure charges just before having surgery. In one case, a patient reportedly did not seek cancer treatment because she was ineligible for free NHS care, and died as a result.

Under the policy, patients who are not entitled to free NHS care – including overseas visitors, but also undocumented immigrants and rejected asylum seekers in England – must pay the cost of treatment upfront unless it is urgent or immediately necessary, or falls within exempt categories which include maternity care, accident and emergency and infectious diseases.

The BMA report is based on a survey of members’ experiences of the effect of upfront charging. Of 285 respondents to a question about the deterrent effect of charging, 35% said patients were being deterred from accessing care, while 24% said they were not. One anonymous respondent told the BMA, “I had a patient who did not seek help for a rare eye cancer, as she was ineligible for NHS treatment. She died in her 40s as a result of this.”

The BMA found one case in which a 60-year-old patient was told, just before an operation, that it would cost her £6,000. Numerous other respondents described patients going without antenatal or postnatal care for fear of being charged.

Dr Yannis Gourtsoyannis, an infectious diseases doctor, told The Guardian about his experiences at previous trusts he has worked for. “I’ve seen patients discharged hastily as a result of their immigration status and, therefore, not receiving equal treatment that other patients would have received. I’ve seen patients discharged without the appropriate lifesaving follow-up, which they would need going forward over the next few months. I’ve seen several patients who’ve delayed coming to hospital … because of the worries about charging.”

Lucy Jones, director of programmes at Doctors of the World, which runs a clinic in London for patients denied NHS care, said, “We see pregnant women too frightened to get antenatal care, people who are acutely unwell afraid to go to A&E, and hospitals stopping life-saving cancer treatment or pain-relieving palliative care.”

The Department for Health and Social Care has conducted a review into the effect of upfront charging, but has not published it. The shadow health secretary, Jonathan Ashworth, said, “These warnings from clinicians on the frontline that care is being undermined must be taken up by ministers. The government-commissioned review must be published immediately and these ‘hostile environment’ provisions that have been introduced must be subjected to thorough public scrutiny.”

The BMA survey also revealed interference by overseas visitors managers (OVMs) – hospital administrators responsible for managing the charging of patients – in clinical decisions about whether treatment is urgently needed and, therefore, exempt from upfront charging. “I have been told by senior clinicians that they have had pressure exerted on them by the OVMs …” Dr Gourtsoyannis said. “They are encouraged [by OVMs] to inform on patients on the basis of little or circumstantial evidence – a ‘funny name’, for example, or the fact they’ve just come from abroad. And clinicians have complied with that.”

Dr John Chisholm, who chairs the BMA’s medical ethics committee, said, “The role of doctors – and all of their healthcare colleagues – must be to treat and care for patients, not to act as border guards, policing patients’ access to, and payment for, treatment. Treatment for conditions at an advanced stage is also far more extensive and expensive than preventive care or early intervention – meaning the regulations’ core premise of economic saving to the NHS is flawed at best.”

The BMA is calling for a full independent review into the impact of NHS charging, together with new exemptions and safeguards. The government’s impact assessment from July 2017 predicted upfront charging would save the NHS £20m a year – less than 0.02% of NHS England’s £110bn total health spending in 2017-18.

A DHSC spokesperson said, “British taxpayers support the NHS, and it is only right that overseas visitors also make a contribution to our health service, with the money recovered being reinvested back into frontline services so everyone receives urgent care when they need it. Patients must always receive urgent treatment regardless of whether they can pay; hospitals never charge for A&E care or for patients with infectious diseases, and exemptions are in place for the most vulnerable, including asylum seekers.

“Our guidance supports trusts to make decisions on charging, while ensuring the best interests of patients, and we are working with NHS Improvement to make sure providers are applying the regulations and guidance properly.”

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