The Immigration Act 2014 heralds a new ‘crackdown’ on so-called ‘health tourism’ in the UK. The two main changes to health policy that it enacts are designed to control the supposed ‘burden’ that immigrants place on NHS finances by limiting access and recovering costs.
Firstly, the government is changing the definition of ‘ordinarily resident’. This is the status of lawful and proper settlement, previously with no minimum period of residence required, that confers entitlement to an NHS number and, with it, free NHS healthcare. The definition is being restricted to include only those with indefinite leave to remain and to exclude anyone who is subject to immigration control or who has not been in the UK for at least five years.
Secondly, temporary non-European migrants are now expected to pay an obligatory health surcharge of £200 (£150 for students) per year of their stay as part of their visa application process in advance of their arrival in the UK. Some immigrants, such as asylum seekers and victims of human trafficking are exempt from the surcharge.
Doctors though tend to treat everyone who comes through the door, whether of their General Practice (GP) surgery or their hospital’s Accident & Emergency (A&E) wing, as if they have funding in place and they tend not to ask patients about money. Understandably, they view themselves as ‘docs not cops’ and see that potential conflicts of interest loom large between the confidential, patient-centered care they are sworn to deliver and the immigration enforcement activity with which the Home Office wants their help.
It is difficult to police immigration in a healthcare setting. Immigrants themselves often do not know what free healthcare they qualify for. One cannot judge someone’s immigration status by external appearance or foreign language use. Doctors receive no mandatory training on issues of immigration status and generally steer clear of involvement in its enforcement. There are no systematic checks on a patient’s immigration status in healthcare settings, although upon initial presentation questions are encouraged about someone’s background if clinically relevant.
Hospitals do have clerical staff in Overseas Offices to whom foreign patients can be referred by clinicians to check on their eligibility for free care, although such referrals are infrequent. Sometimes, by the time a referral is followed up, the patient has been treated and left. It can then be extremely difficult to trace patients who have only been in hospital for a brief time.
In a notable recent development, plain-clothed Home Office immigration staff are now stationed undercover in some hospitals’ A&E departments and maternity wards as part of an initiative to identify patients who may be chargeable for their treatment because of their immigration status. Such initiatives are perhaps more likely in hospitals near to major ports of entry such as Heathrow airport or the St Pancras Eurostar Terminal.
Clearly, there is a danger that, as the government makes healthcare a more hostile and more costly environment for migrants, individual poorly migrants may delay their presentation, skipping primary care altogether and turning up at A&E further down the line when their illness is further progressed. For them, of course, this can have profoundly negative medical implications.
The government may be wielding a cumbersome sledgehammer to crack a tiny nut. Despite certain politicians’ rhetoric, there is little evidence of widespread ‘health tourism’ to the UK, which, according to imprecise government estimates, may cost the country’s health system in the region of £70 million a year – a drop in the £100 billion NHS England ocean. In a survey of migrants visiting Doctors of the World’s specialist clinic in Bethnal Green in east London, fewer than 3 per cent of respondents cited health problems as a reason for their migration to Britain. It seems highly likely that a complex bureaucracy to police immigration status in the NHS would therefore cost more than it might save, especially given the difficulties of recouping costs from those who can’t afford to pay. Moreover, let us not forget that there are Brits too who spend whole lifetimes abroad and then return to the UK in their latter years for free NHS treatment, having paid next to nothing in UK taxes along the way.
The prospect of the government consulting on extending charges for certain migrants further into initial primary care and A&E remains. These services are currently free and provided on the basis of need rather than ability to pay. Very few irregular migrants attend GP surgeries anyway as things stand: one has to register with a GP before seeing a doctor, and it is very hard to register if one is here irregularly. Instead, undocumented migrants tend to wait longer for symptoms to develop and then go straight to hospital, presenting in A&E where their emergency treatment ends up being more expensive to the NHS than preventative interventions would have been earlier in the development of their disease.
The Home Office is intent on enlisting the support of other Whitehall departments in its immigration enforcement work. Health, however, seems to be the public policy area in which the cost-benefit analysis of such an approach is least convincing and where professional cultural resistance is especially strong. Put simply, no doctor swears their Hippocratic oath so that they can help out with border patrol. As for the rest of us, do we really want health checks as checkpoints or médicins comme frontières?